What is GONZALES HEALTHCARE CENTER's CMS rating?

GONZALES HEALTHCARE CENTER has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does GONZALES HEALTHCARE CENTER have any serious inspection findings?

Yes, GONZALES HEALTHCARE CENTER has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 52 total deficiencies from recent inspections.

What are the staffing levels at GONZALES HEALTHCARE CENTER?

GONZALES HEALTHCARE CENTER has a three-star staffing rating from CMS with 0.29 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is GONZALES HEALTHCARE CENTER located?

GONZALES HEALTHCARE CENTER is located in GONZALES, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does GONZALES HEALTHCARE CENTER have?

GONZALES HEALTHCARE CENTER has 120 certified beds.

Who owns GONZALES HEALTHCARE CENTER?

GONZALES HEALTHCARE CENTER is a for profit - corporation facility and is part of the NEXION HEALTH chain.

Is GONZALES HEALTHCARE CENTER safe?

GONZALES HEALTHCARE CENTER has documented safety concerns including a substantiated abuse finding on record, 2 immediate jeopardy citations. Families should ask about corrective actions taken.

Do nurses at GONZALES HEALTHCARE CENTER stick around?

GONZALES HEALTHCARE CENTER has average staff turnover at 42%, which is typical for the nursing home industry.

Was GONZALES HEALTHCARE CENTER ever fined?

Yes, GONZALES HEALTHCARE CENTER has been fined $92,032 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is GONZALES HEALTHCARE CENTER on any federal watch list?

No, GONZALES HEALTHCARE CENTER is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at GONZALES HEALTHCARE CENTER?

Medicare inspectors have found 52 deficiencies at GONZALES HEALTHCARE CENTER: 2 critical, 1 serious, 49 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting GONZALES HEALTHCARE CENTER?

Families visiting GONZALES HEALTHCARE CENTER should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does GONZALES HEALTHCARE CENTER compare to other nursing homes?

GONZALES HEALTHCARE CENTER has a 1-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

GONZALES HEALTHCARE CENTER | 0/100 (Grade F)

May 2025 3 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Based on observations, interview, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (Resident #6, Resident #12) of 4 (Resident #6, Resident #12, Resident...

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Based on observations, interview, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (Resident #6, Resident #12) of 4 (Resident #6, Resident #12, Resident #37, Resident #51) sampled residents investigated for accommodation of needs. Findings: Review of the facility's Resident Call System policy, dated 10/2022 , reviewed on 03/28/2025 , revealed, in part, each resident will be provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Resident #6 Review of Resident #6's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/06/2025 revealed, in part, Resident #6 required substantial and/or maximal assistance for activities of daily living (ADL) from staff. Observation on 05/05/25 at 11:11AM revealed Resident #6 was lying in bed and Resident #6's call light was noted out of reach, lying underneath the bed. Resident #12 Review of Resident #12's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/22/2025 revealed, in part, Resident #12 was dependent on staff for Activities of Daily Living (ADLs) Observation on 05/05/2025 at 11:12AM, revealed Resident #12 was lying in bed and Resident #12's call light was hanging at the head of the bed out of reach. Further observation revealed Resident #12 was unable to reach the call light when she reached for it. In an interview on 05/07/2025 at 1:18PM S1Director of Nursing (DON) indicated it is the facility's policy for call lights to be within reach at all times for all residents.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record reviews, the facility failed to ensure a resident's care plan intervention for a low air loss mattress to bed was in place for 1 (Resident #6) of 2 (Residen...

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Based on observation, interview, and record reviews, the facility failed to ensure a resident's care plan intervention for a low air loss mattress to bed was in place for 1 (Resident #6) of 2 (Resident #6, Resident #30) sampled residents investigated for pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device). Findings: Review of the facility's Quality Assurance (QA) Meeting Minutes dated 04/29/2025 revealed, no documentation that wound management or missing medical equipment was discussed or tracked as part of the facility's QA monitoring. Review of Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/2025 revealed, in part, Resident #6 had a diagnosis of a Stage IV Pressure Ulcer (PU) (a wound that extends into deep tissues including muscle, tendons, and ligaments). Review of Resident #6's Weekly Wound Observation Tool dated 04/29/2025 revealed, in part, Resident #6 had a Stage IV PU to the sacrum. Review of Resident #6's active May 2025 Physician's Orders revealed, in part, an order for a Low Air Loss (LAL) mattress (medical mattress designed to treat and prevent pressure ulcer with air-filled chambers that slowly release air to keep skin dry and reduce pressure on the body) to bed and to ensure that the bed was functioning properly every shift for pressure prevention and wound healing. Review of Resident #6's Stage IV PU care plan revealed, in part, an intervention for LAL mattress to bed. Observation on 05/07/2025 at 12:10PM revealed, in part, Resident #6 lying in bed on a mattress that was not a low air low mattress. Review of Resident #6's general nurse's note dated 04/23/2025 revealed, in part, the medical equipment supplier picked up Resident #6's LAL mattress and pump. In an interview on 05/07/2025 at 1:53PM S1Director of Nursing confirmed the mattress on Resident #6's bed was not a LAL mattress and Resident #6 should have one as ordered by the physician and per Resident #6's plan of care.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observations and interviews the facility failed to: 1. ensure expired medications were not available for resident use on 2 (Medication Cart c, Medication Cart e) of 2 (Medication Cart c, Medi...

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Based on observations and interviews the facility failed to: 1. ensure expired medications were not available for resident use on 2 (Medication Cart c, Medication Cart e) of 2 (Medication Cart c, Medication Cart e) medication carts observed; 2. ensure expired medications were not available for resident use in 2 (Medication Room h, Medication Room g) of 2 (Medication Room h, Medication Room g) medication rooms observed; and, 3. ensure food items were not stored in the medication room for 1 (Medication Room g) of 2 (Medication Room h, Medication Room g). Findings: Observation on 05/07/2025 at 9:19AM, revealed a bottle of Fish Oil 1000 milligrams (mg) capsule which expired on 02/2025 available for resident use on Medication Cart c. In an interview on 05/07/2025 at 9:20AM, S3Licensed Practical Nurse (LPN) indicated the above mentioned medication should not have been on the Medication Cart. Observation on 05/07/2025 at 9:33AM revealed a half-eaten cake on the counter in Medication Room g. In an interview on 05/08/2025 at 9:36AM, S4Registered Nurse indicated the cake should not have been stored in the medication room. Observation on 05/07/2025 at 10:26AM, revealed Dakin's Solution (a solution used for wound care) which expired on 04/2024 and Vashe (a solution used for wound care) which expired on 04/30/2025 available for resident use in Medication Room h. Observation on 05/07/2025 at 10:28AM revealed Dakin's Solution which expired on 02/2024 available for resident use on Medication Cart e. In an interview on 05/07/2025 at 10:30AM, S5LPN indicated the expired Dakin's Solution and Vashe should not have been available for resident use. In an interview on 05/07/2025 at 3:45PM, S1Director Of Nursing confirmed a half-eaten cake should not be stored in the medication room and expired medication should not be available for resident use.

Mar 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident remained free from neglect when nursing staff f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident remained free from neglect when nursing staff failed to provide peri-care for 1(Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for neglect. Findings: Review of the facility's Abuse Prohibition Policy, dated 05/17/2024, revealed, in part, neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Review of Resident #3's medical records revealed, in part, Resident #3 was admitted to the facility on [DATE], with diagnoses of dysphagia following cerebral infarction, generalized muscle weakness, other lack of coordination, unsteadiness on feet, and neuromuscular dysfunction of bladder. Review of Resident #3's quarterly Minimum, Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/2025 revealed, in part, Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #3 was cognitively intact. Further review revealed Resident #3 was always incontinent of bowel and bladder and was dependent upon staff for toileting hygiene needs. Review of Resident #3's Care Plan dated 01/01/2025 revealed, in part, Resident #3 had a neurogenic bladder. Further review revealed interventions included for the facility's staff to perform incontinent care on Resident #3 during daily care and as needed (PRN), to change Resident #3's clothing PRN after incontinence episodes, and to provide Resident #3 with briefs/incontinent pads as needed. Review of the facility's Statewide Incident Management System SIMS investigation completed by S1Administrator, dated 02/02/2025, revealed, in part, Resident #3 alleged she was neglected by S4Certified Nursing Assistant (CNA) and S5CNA when she was left wet and dirty for an extended period of time. Review also revealed, Resident #3's oncoming CNAs confirmed Resident #3's allegations and reported they found Resident #3 wet, over saturated and dirty brief. Review further revealed that S4CNA indicated he viewed the schedule for that shift and he was not assigned to Resident #3's room, but S5CNA indicated she had a verbal conversation with S4CNA about him adding Resident #3 to his assignment. Review also revealed S6Licensed Practical Nurse (LPN) indicated she was not aware of any changes in the CNAs assignment on 02/02/2025, and S5CNA recorded ADL documentation on 02/02/2025 for Resident #3 and his roommate. Further review revealed Resident #3's allegation of neglect was substantiated by the facility. In an interview on 03/10/2025 at 3:44PM, S2Director of Nursing (DON) confirmed that the miscommunication about the assignment for 02/02/2025 between S4CNA and S5CNA did result in Resident #3 being neglected by the staff, and it should not have.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Based on interviews and record reviews, the facility failed to implement the facility's abuse policy by failing to ensure staff reported an allegation of abuse for 1 (Resident #1) of 3 (Resident #1, R...

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Based on interviews and record reviews, the facility failed to implement the facility's abuse policy by failing to ensure staff reported an allegation of abuse for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Prohibition policy and procedure, revised on 05/17/2024, revealed in part, each resident had the right to be free from abuse and mistreatment. Further review revealed verbal abuse was defined as use of oral language that willfully included derogatory terms to residents. Further review revealed any employee who became aware of an allegation of abuse should report the incident to the abuse coordinator immediately. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 01/17/2025 revealed, in part, Resident #1 had a Brief Interview of Mental Status score of 15, which indicated Resident #1's cognition was intact. In an interview on 03/03/2025 at 11:21AM, Resident #1 indicated S7Certified Nursing Assistant (CNA) was disrespectful to her last night and told her to shut up. Resident #1 further indicated the allegation of verbal abuse was reported to the social worker this morning on 03/03/2025. In an interview on 03/06/2025 at 12:03PM, S9Social Service Assistant (SSA) indicated on 03/03/2025 Resident #1 alleged that an unknown CNA told her to shut up. S9SSA further indicated she did not report the allegation of verbal abuse to anyone. In an interview on 03/06/2025 at 12:40PM, S1Administrator indicated he was not aware of Resident #1's allegation that an unknown CNA told her to shut up. S1Administrator confirmed the allegation of verbal abuse should have been reported to him immediately by S9SSA, and was not.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interviews and record reviews, the facility failed to report an allegation of abuse and/or neglect to the State Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled...

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Based on interviews and record reviews, the facility failed to report an allegation of abuse and/or neglect to the State Agency for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Prohibition policy and procedure, revised on 05/17/2024, revealed in part, mental abuse was defined as humiliation and threats of depravation, examples of verbal/mental abuse included denying food or care. Further review revealed the facility would report all allegations of abuse to the State Agency immediately or within two hours of the allegation. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 01/17/2025 revealed, in part, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #1's cognition was intact. Further review revealed Resident #1 had a diagnosis of cerebral palsy (a condition that affects muscle control and causes deficits in functional mobility), impaired range of motion in her bilateral upper extremities, and was dependent on staff for eating. Review of the facility's Life Satisfaction Rounds dated 03/03/2025 documented by S9Social Service Assistant (SSA) revealed, in part, Resident #1 alleged S8CNA told her to learn how to feed herself. In an interview on 03/06/2025 at 12:03PM, S9SSA confirmed she completed the above mentioned Life Satisfaction Rounds on 03/03/2025. S9SSA indicated on 03/03/2025 Resident #1 alleged S8CNA told her she needed to learn how to feed herself. S9SSA further indicated she turned in the above mentioned Life Satisfaction Rounds to S1Administrator on 03/03/2025. Review of the facility's incident reports submitted to the state agency revealed, in part, there was no documented evidence, and the facility did not present any documented evidence Resident #1's allegation of abuse and/or neglect was reported to the State Agency until 03/06/2025. In an interview on 03/06/2025 at 12:40PM, S1Administrator indicated he was aware of the above mentioned Life Satisfaction Round dated 03/03/2025 which indicated S8CNA told Resident #1 to learn how to feed herself. S1Administrator further indicated he did not report the allegation of abuse and/or neglect to the State Agency until 03/06/2025.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected 1 resident

Based on interview and record review, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented ...

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Based on interview and record review, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after many allegations of abuse and neglect were identified in 2024. Findings: Review of the facility's Quality Assessment and Assurance (QAA) policy and procedure last reviewed on 01/2024 revealed, in part, the QAA committee would develop and implement appropriate plans of action to correct identified deficiencies. Review of the facility's Immediate Plan of Improvement: Abuse and Neglect record dated 01/05/2025 revealed, in part, the facility identified a concern of having many abuse and neglect allegations in 2024. Further review revealed the corrective actions implemented by the facility were to initiate staff in-services on types of abuse and the importance of reporting suspected abuse or neglect immediately to the abuse coordinator (S1Administrator). Further review revealed the facility would implement a monthly in-service on abuse with staff, monitor the number of facility incident reports submitted to the state agency, and review the reports for any additional interventions that could be put in place. Review of the facility's QAA documentation revealed an in-service on abuse policies and procedures was completed on 01/05/2025 and an in-service on workplace aggression/violence was completed on 01/09/2025. Further review revealed no documented evidence and the facility did not present any evidence an in-service on abuse was completed with staff in the month of February 2025. Further review revealed no documented evidence and the facility did not present any evidence the facility evaluated the effectiveness of the abuse in-service training completed in January 2025. Further review revealed no documented evidence and the facility did not present any documented evidence of the monitoring, evaluation, or findings of the facility reported incidents. In an interview on 03/06/2025 at 3:05 PM, S1Administrator indicated he could not provide documentation showing how the facility monitored the effectiveness of the abuse in-services. S1Administrator further indicated he could not provide evidence the facility monitored and/or evaluated the facility reported incidents because he kept all the information in his head. S1Administrator further indicated the facility did not need to monitor the effectiveness of the abuse in-services because effectiveness could be determined by the number of facility incidents reported to the state agency concerning abuse. When S1Administrator was asked to clarify if the facility's plan was to wait for an incident of abuse or neglect to happen to a resident as opposed to monitoring the effectiveness of the staff's abuse training, S1Administrator responded, What's wrong with that?

Nov 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to keep a resident free from staff to resident verbal abuse for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled resi...

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Based on record reviews and interviews, the facility failed to keep a resident free from staff to resident verbal abuse for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy Revised 01/01/2024 revealed, in part: Intent: This protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Policy: The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. Definitions: Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal/mental abuse include, but are not limited to, cursing, yelling, saying things to frighten a resident, denying food or care, isolating resident, etc. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 09/22/2024 revealed, in part, Resident #1's Brief Interview for Mental Status (BIMS) score was a 15, which indicated her cognition was intact. Review of Resident #1's care plan revealed, in part, Resident #1 required staff assistance for meeting emotional, intellectual, physical, and social needs. Review of S2Regional [NAME] President (S2RVP) statement on 10/10/2024 revealed, in part, on 10/10/2024 I (S2RVP) was walking down Hall A, S4 Former Activities Director (S4FAD) was entering a resident's room when I (S2RVP) was coming up the hall. I (S2RVP) heard and saw S4FAD talking to Resident #1 with a raised voice. S4FAD told Resident #1 she needed to stop all that crying. I (S2RVP) witnessed S4FAD pointing her finger at Resident #1. In an interview on 11/04/2024 at 10:38 a.m., Resident #1 indicated the incident between her and S4FAD on 10/10/2024 started in the dining room. Resident #1 indicated she inquired about going to a health fair on 10/15/2024. Resident #1 indicated S4FAD told her they would not be able to accommodate the residents who wanted to go because the smaller van was broken and the other van would be used to bring residents to doctors' appointments. Resident #1 indicated later on the same day S4FAD came to her room and she again asked S4FAD about the health fair and that is when things got heated. Resident #1 stated S4FAD yelled that if she was going to an appointment then she would not want to miss her doctor's appointment. Resident #1 stated she yelled back at S4FAD, and they were going back and forth yelling at each other. In an interview on 11/04/2024 at 11:19 a.m., S2VP indicated he witnessed S4FAD walk into Resident #1's room and heard S4FAD speaking loudly to Resident #1. S2VP stated he heard S4FAD speaking to Resident #1 in a loud and verbally inappropriate way, that, we were not going to keep doing this. S2VP further indicated S4FAD was verbally inappropriate to Resident #1. In an interview on 11/06/2024 at 12:06 p.m., S1Administrator stated he substantiated that S4FAD verbally abused Resident #1, and should not have.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0680 (Tag F0680)

Could have caused harm · This affected 1 resident

Based on record reviews and interview, the facility failed to ensure the activities program was directed by a qualified professional for 1 (S4Former Activities Director) of 1 (S4Former Activities Dire...

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Based on record reviews and interview, the facility failed to ensure the activities program was directed by a qualified professional for 1 (S4Former Activities Director) of 1 (S4Former Activities Director) staff personnel files reviewed for activities director qualifications. Findings: Review of the facility's job description for the Activities Director revealed, in part, the following education and experience requirements: Education: must possess, as a minimum, two years of college. Degree preferred but not necessary. Experience: Must be a qualified therapeutic recreation specialist or an activities professional who is licensed by this state and is eligible for certification as a recreation specialist or as an activities professional; or Must have a minimum two year experience in a social or recreation program within the last five years, one of which was full time in a patient activities program in a health care setting; or Must be a qualified occupational therapist or occupational therapy assistant; or Must have completed a training course approved by this state. Review of S4FAD's personnel record revealed no documented evidence, and the facility did not present any documented evidence, S4FAD had any qualifications required in the facility's job description for Activities Director. The facility did not provide any documentation that S4FAD had any of the listed qualifications for Activities Director. In an interview on 11/06/2024 at 11:47 a.m., S1Administrator indicated the facility did not have any documentation S4FAD was qualified for the position of Activities Director as required.

Sept 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interviews and record review the facility failed to ensure the investigation of an allegation of neglect was reported to the State Survey agency within the required time frame for 2 (Resident...

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Based on interviews and record review the facility failed to ensure the investigation of an allegation of neglect was reported to the State Survey agency within the required time frame for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated. Findings: Resident #1 Review of the Health Standards Incident Report (HSIR) dated 09/03/2024 at 9:18 a.m. revealed, in part, a an allegation of neglect involving Resident #1 was reported to the State Survey Agency on 09/03/2024 at 9:18 a.m. Further review revealed a final investigation report was due on 09/10/2024 at close of business. Review of S2Interim Administrator's email dated 09/10/2024 at 4:12 p.m. revealed, in part, S2Interim Administrator emailed a State Survey Agency Program Manager to request an extension for the due date to report the results of the above mentioned investigation. Review of an email dated 09/10/2024 at 4:31 p.m. revealed, in part, an extension was granted for 09/12/2024 by close of business. Review the HSIR dated 09/10/2024 revealed, in part, S1Administrator sent the final investigation report to the State Survey Agency on 09/16/2024 at 1:35 p.m. In an interview on 09/17/2024 at 9:52 a.m., S1Administrator indicated a State Survey Agency Program Manager extended the due date for the final report of the above mentioned investigation until 09/12/2024. S1Administrator further indicated he did not send the final report of the investigation into the allegation of neglect involving Resident #1 to the State Survey Agency until he returned to work on 09/16/2024. In an interview on 09/17/2024 at 12:46 p.m. S2Interim Administrator indicated she performed the final investigation report for Resident #1 and did not have access to enter the final investigation report to the State Survey Office. In an interview on 09/17/2024 at 1:33 p.m. S3Corporate Clinical Specialist indicated the final investigation report for Resident #1 was sent to State Office on 09/16/2024 at 1:35 p.m. Resident #3 Review of the HSIR dated 09/03/2024 at 10:35 a.m. revealed, in part, an allegation of neglect involving Resident #3 was reported to the State Survey Agency on 09/03/2024 at 10:35 a.m. Further review revealed a final investigation report was due on 09/10/2024 at close of business. Review of S2Administrator's email dated 09/10/2024 at 4:12 p.m. revealed, in part, S2Interim Administrator emailed a State Survey Agency Program Manager to request an extension for the due date to report the results of the above mentioned investigation. Review of an email dated 09/10/2024 at 4:31 p.m. revealed, in part, an extension was granted an extension for 09/12/2024 by close of business. Review the HSIR dated 09/10/2024 revealed, in part, S1Administrator sent the final investigation report to the State Survey Agency on 09/16/2024 at 2:05 p.m. In an interview on 09/17/2024 at 9:52 a.m., S1Administrator indicated a State Survey Agency Program Manager extended the due date for the final report of the above mentioned investigation until 09/12/2024. S1Administrator further indicated he did not send the final report of the investigation into the allegation of neglect involving Resident #3 to the State Survey Agency until he returned to work on 09/16/2024. In an interview on 09/17/2024 at 12:46 p.m. S2Interim Administrator indicated she was unable to submit the final investigation report for the allegation of neglect involving Resident #3 because she did not have access to the State Incident Management System (SIMS). In an interview on 09/17/2024 at 1:33 p.m. S3Corporate Clinical Specialist indicated the final investigation report for Resident #1 was sent to State Office on 09/16/2024 at 1:35 p.m.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interviews and record reviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Residen...

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Based on interviews and record reviews, the facility failed to ensure a thorough investigation was completed for an allegation of neglect for 2 (Resident #2 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled resident investigated for neglect. Findings: Review of the facility's policy titled Abuse Prohibition last reviewed on 05/17/2024 revealed, in part, the facility will thoroughly investigate all alleged violations of neglect and take appropriate actions. Further review revealed the facility was to conduct interviews and/or obtain written statements from individuals, (residents, visitors, or staff) who may have firsthand knowledge of the incident. Review of the Health Standards Incident Report (HSIR) revealed, in part, there was an allegation of neglect involving Resident #2 for timely incontinence care. Resident #2 Review of S5Licensed Practical Nurse (LPN) 's witness statement pertaining to an investigation regarding an allegation of neglect involving Resident #2 revealed, in part, the witness statement was a photocopy of an alleged conversation between S5LPN and S1Administrator. Further review revealed, S5LPN's signature was not present on the above mentioned statement to prove the validity of the statement Review of S5LPN's witness statement pertaining to an investigation regarding an allegation of neglect involving Resident #2 revealed, in part, the witness statement was a photocopy of an alleged conversation between S5LPN and S1Administrator. Further review revealed, S5LPN's signature was not present on the above mentioned statement to prove the validity of the statement. Review of S4Certified Nursing Assistant (CNA)'s witness statement pertaining to an investigation regarding an allegation of neglect involving Resident #2 revealed, in part, S4CNA's signature was not present on the above mentioned statement to prove the validity of the statement. In an interview on 09/17/2024 at 3:05 p.m. S1Administrator indicated a photocopy of a text message from allegedly S5LPN should not have been used as a witness statement in an investigation of neglect for Resident #2. S1Administrator further indicated S5LPN and S4CNA should have signed their witness statements. Resident #3 Review of the Health Standards Incident Report (HSIR) revealed, in part, there was an allegation of neglect involving Resident #3 for timely incontinence care. There was no documented evidence and the facility did not present any evidence S2Interim Administrator conducted an interview with Resident #3 regarding the above mentioned allegation of neglect. In an interview on 09/17/2024 at 12:46 p.m. S2Interim Administrator indicated she did not get a witness statement from Resident #3 as part of her investigation regarding he allegation of neglect involving Resident #3.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected 1 resident

Based on interview and record review, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented ...

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Based on interview and record review, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence that ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identification of residents not receiving incontinence care as needed. Findings: Review of the facility's policy title, Quality Assurance Policy and Procedure last revised on March 2023 revealed, in part, the Quality Assessment and Assurance (QAA) committee would regularly review and analyze data collected and make improvements. Further review revealed the QAA committee would develop and implement appropriate plans of action to correct identified quality deficiencies. Review of the facility's QAA Plan of Action and Implementation record revealed, in part, a plan of action was implemented for timely documentation for activities of daily living (ADL) on 04/18/2024 as a result of deficient practice cited on a prior complaint survey conducted on 03/14/2024. Review of Quality Assessment and Assurance Plan of Action and Implementation Record dated 04/18/2024 revealed, in part, all omissions of ADL documentation will be monitored in Point Click Care (software used by the facility for documentation) daily, in-services are to be held with nursing staff to check ADL documentation during every shift and to notify Certified Nursing Assistant/Assistants (CNA) of omission of ADL documentation. Further review revealed nursing staff are responsible to ensure documentation is entered into Point Click Care by the end of every shift and administrative nursing staff are to check omissions of ADL documentation daily and to notify CNA of omissions of ADL documentation. Further review revealed all new hired CNA's and current CNA's are to be in-serviced on importance of ADL documentation and documentation must be completed at end of shift. Review of Documentation Survey report for September 2024 for Resident #1 revealed, in part, no documented evidence Resident #1 was assisted by staff with toilet use and/or toilet transfer on the night shift of: 09/01/2024; 09/02/2024; 09/03/2024; 09/04/2024; 09/05/2024; 09/06/2024; 09/07/2024; 09/08/2024; 09/09/2024; 09/10/2024; 09/11/2024; 09/12/2024; 09/13/2024; 09/15/2024; and 09/16/2024. In an interview on 09/17/2024 at 4:05 p.m. S3Corporate Clinical Specialist indicated there was no documentation of staff assisting Resident #1 with toilet use and transfer on the above mentioned dates. In an interview on 09/18/2024 at 2:43 p.m. S6Director of Nursing (DON) indicated she could not produce any documented evidence of an audit tool for ADL documentation monitoring per the facility's QAA plan. S6DON further indicated the QAA plan was not being followed by CNA's, and could not provide any documented evidence the QAA plan was revised nor documented evidence of staff disciplinary action for not following the QAA plan. S6DON indicated she could not produce any documented evidence all staff was in-serviced on ADL documentation for September 2024.

Sept 2024 2 deficiencies 2 IJ (2 facility-wide)

CRITICAL (L) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly secure residents in the facility's transpor...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly secure residents in the facility's transportation vehicles for 2 (Resident #5 and Random Resident #6) of 2 (Resident #5 and Random Resident #6) sampled residents reviewed for accident hazards. This deficient practice resulted in an Immediate Jeopardy situation on 08/22/2024 at 11:47 a.m. for Resident #5 when S6Driver failed to properly secure the resident in a forward facing direction in the facility's transportation bus, Resident #5's wheelchair tipped over backwards during transport, and caused Resident #5 to strike the back of her head. Resident #5 was transported to the hospital where she was assessed as having an abrasion to the back of the head and had to receive pain medication. The IJ continued on 09/03/2024 at 12:30 p.m. for Random Resident #6, when S4ActivitiesDirector (AD) was observed failing to secure Random Resident #6 into the facility's transport van using both the lap belt and the shoulder strap and left the facility with Random Resident #6 improperly restrained. S1Administrator was notified of the Immediate Jeopardy on 09/03/2024 at 5:59 p.m. The Immediate Jeopardy was removed on 09/04/2024 at 2:39 p.m., after it was verified through observations, interviews, and record reviews, that the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimal harm to the 75 residents who resided in the facility and may use the use of the facility's transportation vehicles. Findings: Resident #5 Review of the facility's Policy and Procedure titled Securing Residents in Van dated 04/2015 revealed, in part, the driver shall ensure residents in wheelchairs are forward facing in vehicles. Review of Resident #5's Electronic Medical Record (EMR) revealed, in part, Resident #5 was admitted to the facility on [DATE] with diagnoses of muscle weakness, cognitive communication deficit, and lower back pain. Review of Resident #5's care plan with a planned review date of 09/29/2024 revealed, in part, Resident #5 was at high risk for falls due to confusion and gait/balance problems. Review of S6Driver's written and signed statement revealed, in part, Resident #5 was being transported in the facility bus, when the van hit a bump in the road. S6Driver then saw Resident #5's wheelchair had tipped backwards. Further review revealed S6Driver did not have Resident #5 forward facing in the facility vehicle. Review of Resident #5's medical records revealed, in part, Resident #5 was evaluated at a local emergency department on 08/22/2024 for a head injury sustained during transport in the facility's bus. Review of Resident #5's nurse's notes dated 08/22/2024 revealed, in part, Resident #5 had an abrasion to the back of her head. Further review revealed Resident #5 received pain medication while in the emergency department. In an interview on 09/03/2024 at 11:30 a.m., S1Administrator indicated Resident #5 was not secured in accordance with facility transportation guidelines. In an interview on 09/05/2024 at 11:30 a.m., S5Maintenance Director (MD) indicated resident wheelchairs should be secured to the transport vehicle using 4 straps and forward per the training videos related to vehicle safety. S5MD further indicated if a wheelchair is strapped down properly it should not move or tip over. Random Resident #6 Review of Facility's Policy and Procedure entitled Securing Residents in Van dated 04/2015 revealed, in part, the driver shall ensure the shoulder straps cross diagonally across the upper chest of the passenger. Review of Random Resident #6's record revealed, in part, Random Resident #6 was admitted to the facility on [DATE] with diagnoses of muscle weakness, hemiplegia, and intervertebral disc degeneration. Review of Random Resident #6's care plan with a planned review date of 09/01/2024 revealed, in part, Random Resident #6 was a high risk for falls and at risk for bleeding if a fall would occur. Observation on 09/03/2024 at 12:08 p.m., revealed S4AD loaded Random Resident #6 in the facility's transportation van without using the vehicle's installed shoulder straps. In an interview on 09/03/2024 at 12:15 p.m., S4AD indicated Random Resident #6 did not need to use the shoulder strap to secure residents in the facility transport vehicles. S4AD further indicated she did not routinely use the shoulder strap when she transported residents. Observation on 09/03/2024 at 12:30 p.m. revealed S4AD left the facility, and transported Random Resident #6 in the facility's transportation van without securing Random Resident #6 with the shoulder straps. In an interview on 09/03/2024 at 12:55 p.m., S5MD indicated the shoulder harness should always be used to secure residents in the facility's transport van. S5MD further indicated S4AD should have used the shoulder strap prior to transporting Random Resident #6. In an interview on 09/03/2024 at 1:10 p.m., S1Administrator indicated Resident #6 should have been secured with the shoulder belt.

CRITICAL (L) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequat...

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Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure residents were properly restrained in the facility's transportation vehicles, vehicle transportation logs were completed as required for the facility's transportation vehicles, and the facility's transportation drivers were competent on the use of the facility's van and bus restraint systems prior to transporting residents. This lack of administrative oversight resulted in an Immediate Jeopardy situation on 08/22/2024 at 11:47 a.m. for Resident #5 when S6Driver failed to properly secure the resident in a forward facing direction in the facility's transportation bus, Resident #5's wheelchair tipped over backwards during transport, and caused Resident #5 to strike the back of her head. Resident #5 was transported to the hospital where she was assessed as having an abrasion to the back of the head and had to receive pain medication. The IJ continued on 09/03/2024 at 12:30 p.m. for Random Resident #6, when S4ActivitiesDirector (AD) was observed failing to secure Random Resident #6 into the facility's transport van using both the lap belt and the shoulder strap and left the facility with Random Resident #6 improperly restrained. S1Administrator was notified of the Immediate Jeopardy on 09/03/2024 at 5:58 p.m. The Immediate Jeopardy was removed on 09/04/2024 at 2:39 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimal harm to the 75 residents who resided in the facility and may use the facility's transportation vehicles. Findings: Cross reference F689. Review of the facility's job description for the Administrator dated 2003 revealed, in part, the Administrator shall ensure all facility personnel follow established safety regulations. Review of the facility's policy titled Facility Vehicle Log dated 04/2015 revealed, in part, the van use log will be completed by the driver for each trip. Further review revealed the driver's weekly vehicle safety inspection will be completed by the driver each week. Review of the facility's Van Use Log for the transport bus revealed, in part, incomplete entries for mileage and times. Further review revealed no entry dated 08/22/2024 for Resident #5's initial transport by S6Driver in which the fall with injury occurred. Review of the facility's Driver Weekly Safety Inspection log for bus #09796 dated 08/02/2024, 08/09/2024, and 08/23/2024 revealed, in part, blank forms with no entries or inspections performed. Review of the facility's Quality Assurance (QA) Plan for transporting residents safely in facility vehicles dated 08/27/2024 revealed, no documented evidence, and the facility could not provide any documented evidence, that weekly driver audits were performed from 08/27/2024 through 09/03/2024 or that an immediate in-service safety training for all drivers was performed from 08/27/2024 to 09/03/2024. In an interview on 09/03/2024 at 1:10 p.m., S1Administrator indicated the facility's transportation drivers should secure the facility's residents in the transportation vehicles according to the manufacturer's instructions and facility policy. S1Administrator further indicated he was aware the transported residents should have both a lap belt and shoulder strap during transport in a facility vehicle. S1Administrator offered no explanation or comment related to the deficient practice. In an interview on 09/03/2024 at 1:50 p.m., S1Administrator confirmed there had been no weekly driver audits performed since the QA plan for transporting residents safely in facility vehicles began on 08/27/2024. In an interview on 09/04/2024 at 10:00 a.m., S1Administrator indicated he was overall responsible for the safety of residents being transported in facility vehicles. S1Administrator further indicated the van's transportation logs should have been reviewed for completeness and accuracy. In an interview on 09/04/2024 at 10:45 a.m., S1Administrator indicated he was overall responsible for the training and competency of the facility's vehicle drivers. In an interview on 09/04/2024 at 11:15 a.m., S5Maintenance Director confirmed there was no documented evidence and he was unable to provide any documented evidence that safety inspections were performed for the weeks of 08/02/2024, 08/09/2024, and 08/23/2024 and should have been. In an interview on 09/04/2024 at 1:15 p.m., S1Administrator indicated the facility was unable to produce any documented evidence that the required weekly safety inspections were performed on transport bus.

Aug 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect a resident's right to be free from verbal abuse by staff....

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect a resident's right to be free from verbal abuse by staff. This deficient practice was identified for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy review dated 05/17/2024 revealed, in part, verbal abuse was defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to the residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Review of the facility's documentation related to an incident dated 07/26/2024 revealed an anonymous bystander from Resident #1's physician's office and staff from Resident #1's physician office reported to the facility that they witnessed S4Transportation Driver (S4TD) refuse to assist Resident #1 with filling out his paperwork and yelled nothing was wrong with his hands he was there for his legs. Review of Resident #1's record revealed he was admitted on [DATE] with diagnoses, in part, of right ankle effusion, sepsis, generalized weakness and injury to left eye. Review of Resident #1's Minimum Date Set with an Assessment Reference Date of 07/25/2024 revealed Resident #1 had a Brief Interview for Mental Status of 14 which indicated Resident #1 was cognitively intact. In an interview on 08/12/2024 at 10:34 a.m. Resident #1 indicated S4TD was rude to him while he was at his physician's appointment. Resident #1 further indicated he needed help filling out his paperwork, and when he requested help S4TD told him there is something wrong with your legs, not your hands, you can do it yourself. In an interview on 08/14/2024 at 1:51 p.m. S1Administrator (ADM) indicated a bystander in the waiting room at Resident #1's physician's office, reported they witnessed S4TD refused to assist Resident #1 with his paperwork and yelled at Resident #1. S1ADM further indicated Resident #1's physician's office corroborated the bystander's report. S4TD was suspended on 07/26/2024 and subsequently was terminated on 08/05/2024 after the facility investigation substantiated the above mentioned verbal abuse occurred.

Jun 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on record review and interview the facility failed to report the results of an investigation to the required state agency within 5 working days of a reportable incident for 1 (Resident #6) of 7 ...

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Based on record review and interview the facility failed to report the results of an investigation to the required state agency within 5 working days of a reportable incident for 1 (Resident #6) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) residents reviewed for abuse and/or neglect. Findings: Review of Resident #6's Facility Reported Incident entered on 05/30/2024 revealed an allegation of neglect. Review of the Facility Reported Incident log documentation revealed Resident #6 had an incident reported on 05/30/2024 and the investigation report was due to the state survey agency on 06/06/2024. In an interview on 06/13/2024 at 1:45 p.m., S4Corporate Clinical Specialist stated the results of Resident #6's investigation were submitted to the state survey agency on 06/07/2024 and should have been submitted by 06/06/2024. .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on record review and interviews, the facility failed to ensure an alleged incident of neglect was thoroughly investigated by the facility for 1 (Resident #4) of 7 (Resident #1, Resident #2, Resi...

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Based on record review and interviews, the facility failed to ensure an alleged incident of neglect was thoroughly investigated by the facility for 1 (Resident #4) of 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) residents reviewed for abuse and/or neglect. Findings: Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024 revealed, in part, Resident #4 had a Brief Interview for Mental Status (BIMS) of 15 which indicated Resident #4's cognition was intact. Further review revealed Resident #4 required substantial/maximal assistance from staff for toileting and partial/moderate assistance from staff for toilet transfers. Review of the Resident #4's facility incident report dated on 05/29/2024 revealed, in part, an investigation was initiated for Resident #4 with an allegation of neglect. Further review revealed Resident #4 reported problems receiving timely care from the night staff. S1Administrator documented Resident #4 was not forthcoming with information and provided no specific date or time pertaining to the allegation. S1Administrator also documented the facility reviewed the call system log and noted Resident #4 had to wait an extended amount of time for assistance on one occasion but did not document a date or time the incident occurred. Further review revealed there was no documented evidence the facility investigated why Resident #4 had to wait an extended amount of time for assistance or identified the staff member who was caring for the resident at that time. Review of Resident #4's nurse note dated 05/27/2024 at 5:23 p.m. revealed, in part, Resident #4 reported to S5Registered Nurse on the night shifts on 05/25/2024 and 05/26/2024 Resident #4 had to yell out for help to request assistance to the bathroom. Further review revealed Resident #4 reported she pressed her call light and staff would enter and stated they would help her but would leave and never return to provide care. Review of Resident #4's call light alarm log from 05/23/2024 through 05/31/2024 revealed, in part, on 05/27/2024 Resident #4's call light alarm was initiated at 5:16 a.m. and was cleared at 6:52 a.m. for a total of 96 minutes. In an interview on 06/12/2024 at 10:39 a.m., S1Director of Nursing (DON) stated S6Certified Nursing Assistant (CNA) was responsible for Resident #4 on 05/26/2024 at 7 p.m. through 05/27/2024 at 7 a.m. Review of the facility's investigation documentation for Resident #4's allegation of neglect revealed no evidence and the facility did not present any documented evidence a verbal or written statement was obtained from S6Certified Nursing Assistant (CNA) related to the investigation or the extended call light alarm time. In an interview on 06/13/2024 at 11:15 a.m., S1Administrator stated he was aware of the nurse's noted dated 05/27/2024 which indicated Resident #4 alleged she did not receive care in a timely manner from staff on the night shift 05/25/2024 and 05/26/2024. S1Administrator confirmed this information was not included in Resident #4's investigation report. S1Administrator also confirmed a verbal and/or written statement from S6CNA was not included in the facility's investigation documentation for Resident #4 as required.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to ensure a dependent resident received timely incontinence care for 1 (Resident #5) of 4 (Resident #1, Resident #4, Resident #5, and Reside...

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Based on record reviews and interviews, the facility failed to ensure a dependent resident received timely incontinence care for 1 (Resident #5) of 4 (Resident #1, Resident #4, Resident #5, and Resident #6) sampled residents investigated for incontinence care . Findings: Review of Resident #5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/22/2024 revealed, in part, Resident #5 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated Resident #5 had moderately impaired cognition. Further review revealed Resident #5 was incontinent of bowel and bladder, and dependent on staff for toileting. Review of the facility's incident report dated 05/29/2024 revealed, in part, the report was initiated for an allegation of neglect. Further review revealed Resident #5 reported on 05/30/2024 she was not changed by the day shift Certified Nursing Assistant (CNA) on 05/29/2024. Further review revealed the facility identified S7CNA as the accused associate with the allegation and obtained a verbal statement from S7CNA on 05/31/2024. Further review revealed S7CNA confirmed she was assigned to provide care to Resident #5 on the day shift on 05/29/2024 and after lunch she did not go back to Resident #5's room to provide any care or services. Further review of the facility incident report revealed S8CNA was assigned to provide care to Resident #5 on the evening shift on 5/29/2024 and reported Resident #5 was found saturated with urine. In an interview on 06/13/2024 at 12:22 p.m., S8CNA indicated at the start of her shift on 05/29/2024 Resident #5 was found to be saturated with urine through her adult brief onto her incontinence pad and onto the sheets. In an interview on 06/13/2024 at 12:31 p.m., S1Administrator confirmed he obtained a verbal statement from S7CNA which indicated Resident #5 did not receive any care from S7CNA from approximately 11:30 a.m. through the end of her shift at 7:00 p.m. S1Administrator confirmed Resident #5 should not have been left unchanged and/or unattended to on 05/29/2024 from approximately 11:30 a.m. until the next shift provided care.

May 2024 8 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on record review and interviews, the facility failed to report an injury of unknown origin for 1 (Resident #43) of 8 (Resident #11, Resident #20, Resident #23, Resident #37, Resident #43, Reside...

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Based on record review and interviews, the facility failed to report an injury of unknown origin for 1 (Resident #43) of 8 (Resident #11, Resident #20, Resident #23, Resident #37, Resident #43, Resident #47, Resident #75, and Resident #239) sampled residents investigated for abuse. Findings: Review of Resident #43's record revealed an admit date of 10/04/2023 with diagnosis of Alzheimer's disease with late onset. Review of Resident #43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2024 revealed, in part, Resident #43 had a Brief Interview for Mental Status (BIMS) of 6 which indicated she was severely cognitively impaired. Further review revealed there were no documented behaviors. Review of Resident #43's Progress Notes revealed a nurse's note written on 04/19/2024 at 10:15 a.m. by S6Licensed Practical Nurse (LPN) that revealed S10Certfied Nursing Assistant (CNA) informed S6LPN that Resident #43's left cheek and left corner of her lip was swollen and red. In an interview on 05/15/2024 at 10:00 a.m., S6LPN stated on 04/19/2024 upon assessment of Resident #43, she noted her bottom lip was swollen and her left cheek was red. S6LPN further stated she notified Resident #43's primary care doctor and S2Director of Nursing. In an interview on 05/15/2024 at 12:10 p.m., S10Certfied Nursing Assistant (CNA) stated on 04/19/2024 she notified S6LPN Resident #43's cheek was red and her lip was swollen. S10CNA stated Resident #43 could not tell her if anything happened to her to receive a red cheek and swollen lip. In an interview on 05/16/2024 at 2:48 p.m., S1Administrator stated he was unaware of an incident that occurred on 4/19/2024 in which resident was found to have a red cheek and a swollen lip. In an interview on 05/16/2024 at 3:05 p.m., S2Director of Nursing (DON) stated she assessed Resident #43 on 04/19/2024 after she was notified by S6LPN but she did not document the assessment. S2DON stated Resident #43 was unsure of how she developed a red cheek and a swollen lip. S2DON confirmed there was no further investigation into how Resident #43 acquired a red cheek and swollen lip, nor did she report this information to S1Administrator. In an interview on 05/16/2024 at 3:45 p.m., S2DON stated she immediately went to assess the resident right after she read the note because her immediate thought was abuse. S2DON confirmed she did not have any documentation to support her assessment of the resident's lip and cheek. Based on interviews and Resident #43's record review there was no documentation indicating a report for an injury of unknown origin was made. Furthermore, facility failed to produce any documentation that indicated a report for an injury of unknown origin was made.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews the facility failed to investigate an injury of unknown origin for 1 (Resident #43) of 8 (Resident #11, Resident #20, Resident #23, Resident #37, Resident #43, R...

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Based on record reviews and interviews the facility failed to investigate an injury of unknown origin for 1 (Resident #43) of 8 (Resident #11, Resident #20, Resident #23, Resident #37, Resident #43, Resident #47, Resident #75, and Resident #239) sampled residents investigated for abuse. Findings: Review of Resident #43's record revealed an admit date of 10/04/2023 with diagnosis of Alzheimer's disease with late onset. Review of Resident #43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2024 revealed, in part, Resident #43 had a Brief Interview for Mental Status (BIMS) of 6 which indicated Resident #43's cognition was severely impaired. Review of Resident #43's Progress Notes revealed a nurse's note written on 04/19/2024 at 10:15 a.m. by S6Licensed Practical Nurse (LPN) that revealed S10Certfied Nursing Assistant (CNA) informed S6LPN that Resident #43's left cheek and the left corner of Resident #43's lip was swollen and red. In an interview on 05/15/2024 at 12:10 p.m., S10Certfied Nursing Assistant (CNA) stated on 04/19/2024 she notified S6LPN regarding Resident #43's red cheek and swollen lip. S10CNA stated Resident #43 was unable to explain what caused her red cheek and swollen lip. In an interview on 05/15/2024 at 10:00 a.m., S6LPN stated on 04/19/2024 she assessed Resident #43 and noted Resident #43's bottom lip was swollen and Resident #43's left cheek was red. S6LPN further stated she notified Resident #43's primary care doctor and S2Director of Nursing. In an interview on 05/16/2024 at 2:48 p.m., S1Administrator stated he was unaware of an incident that occurred on 4/19/2024 in which Resident #43 was found to have a red cheek and swollen lip. In an interview on 05/16/2024 at 3:05 p.m., S2Director of Nursing (DON) stated she assessed Resident #43 on 04/19/2024 after she was notified by S6LPN but did not document the assessment. S2DON stated Resident #43 was unable to explain what caused her red cheek and swollen lip. S2DON confirmed there was no further investigation into how Resident #43 acquired a red cheek and swollen lip, nor did she report this information to S1Administrator. In an interview on 05/16/2024 at 3:45 p.m., S2DON indicated, after reading the above mentioned nurse note, she assessed Resident #43 immediately because her immediate thought was abuse. S2DON confirmed she did not have any documentation to support her assessment of Resident #43's lip and cheek. Based on interviews and Resident #43's record review there was no documentation indicating an investigation for an injury of unknown origin was made. Furthermore, facility failed to produce any documentation that indicated an investigation for an injury of unknown origin was made.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident did not have an order for administration of a p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident did not have an order for administration of a psychotropic medication (drugs that affect one's mental state) on an as needed basis (PRN) without a physician's documentation of the specified duration of the order for 1 (Resident #46) of 5 (Resident #16, Resident #46, Resident #47, Resident #64, and Resident #82) sampled resident investigated for unnecessary medications. Findings: Review of Resident #46's admission record revealed, in part, Resident #46 was admitted to the facility on [DATE] with diagnoses of unspecified mood disorder and bipolar disorder (a serious mental illness characterized by extreme mood swings of extreme excitement or extreme depressive feelings). Review of Resident #46's May 2024 physician's orders revealed, in part, an order with a start date of 11/20/2023 for Lorazepam (a psychotropic medication used to treat anxiety) 0.5 milligrams (mg) by mouth every 12 hours as needed for anxiety related to bipolar disorder. Review of Resident #46's Pharmaceutical Consultant Report dated 11/28/2023 revealed, in part, a request by the consultant pharmacist for Resident #46's physician to address the order for Lorazepam 0.5mg every 12 hours as needed. Review revealed the consultant pharmacist documented a PRN order for a psychotropic medication was limited to 14 days and required the prescriber to evaluate the resident prior to extending the order. Further review revealed Resident #46's physician documented to continue the use of Resident #46's medications and wrote new admit no change at this time. Resident #46's Pharmaceutical Consultant Report was signed by Resident #46's physician on 12/05/2023. Review of Resident #46's Individual Resident Narcotic Record revealed, in part, documentation Lorazepam 0.5mg was administered to Resident #46 33 times since admission. In an interview on 05/16/2024 at 11:31 a.m., S6Licensed Practical Nurse confirmed Resident #46 had an order for Lorazepam 0.5mg to be administered PRN. There was no documented evidence and the facility did not present any documented evidence Resident #46 had a defined duration of the continued use of the psychotropic medication Lorazepam on a PRN basis after 14 days of the order date. In an interview on 05/16/2024 at 3:09 p.m., S2Director of Nursing confirmed she did not have any documentation from Resident #46's physician regarding the defined duration of Resident #46's PRN Lorazepam order.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to administer a medication for hypertension as ordered...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to administer a medication for hypertension as ordered by the physician for 1 (Resident #14) of 22 (Resident #11, Resident #14, Resident #16, Resident #21, Resident #37, Resident #43, Resident #46, Resident #47, Resident #48, Resident #50, Resident #52, Resident #54, Resident #57,Resident #62, Resident #64, Resident #69, Resident #75, Resident #82, Resident #87, Resident #88, Resident #239, and Resident #440) residents investigated in the sample. Findings: Review of the manufacturers prescribing information for Clonidine revealed, in part, application of a new system to a fresh skin site at weekly intervals continuously maintains therapeutic plasma concentrations of clonidine. If the patch is removed and not replaced with a new system, therapeutic plasma clonidine levels will persist for about 8 hours and then decline slowly over several days. Over this time period, blood pressure returns gradually to pretreatment levels. Resident #14 was admitted to the facility on [DATE] with a diagnosis of, in part, hypertension. Review of Resident #14's May 2024 Physician Orders revealed, in part, Clonidine HCL (hydrochloride) (a medication used to treat high blood pressure) apply 0.1 mg (milligram) transdermally (route of administration where active ingredients are delivered across the skin for systemic distribution) one time a day every Friday related to hypertension. Further review revealed, in part, change Clonidine HCL 0.1mg patch every Friday. Review of Resident #14's May 2024 electronic Medication Administration Record (eMAR) revealed, in part, S5Licensed Practical Nurse (LPN) documented administration of Resident #14's Clonidine 0.1mg patch on 05/10/2024. Observation of Resident #14 on 05/14/2024 at 9:00 a.m. revealed a patch was applied to Resident #14's right upper arm. Observation revealed the patch was dated 05/03/2024. In an interview on 05/14/2024 at 9:10 a.m., S5Licensed Practical Nurse (LPN) confirmed the patch on Resident #14's right upper arm was a Clonidine HCL 0.1mg patch and confirmed the patch was dated 05/03/2024. In an interview on 05/14/2024 at 11:49 a.m., S4Corporate Clinical Specialist and S13LPN confirmed Resident #14's patch on the upper right arm was dated 05/03/2024. S4Corporate Clinical Specialist and S13LPN further stated Resident #14 had no other patches applied on her body. In an interview on 05/16/2024 at 11:53 a.m., S5LPN indicated when she attempted to apply Resident #14's Clonidine HCL 0.1mg on 05/10/2024 the patch would not stick to Resident #14's chest. S5LPN indicated she did apply Resident#14's Clonidine HCL 0.1mg patch on 05/10/2024. S5LPN indicated she failed to remove Resident #14's Clonidine 0.1mg patch which was applied on 05/03/2024. S5LPN indicated she documented administration of Clonidine HCL 0.1mg on Resident #14's May 2024 eMAR on 05/10/2024. S5LPN indicated she did not notify Resident #14's physician of the failure to apply the Clonidine HCL 0.1mg patch until 05/14/2024. In an interview on 05/16/2024 at 12:15pm, S4Corporate Clinical Specialist indicated Resident #14's physician should have been immediately notified of the failure to apply Resident #14's Clonidine 0.1mg HCL patch on 05/10/2024.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to obtain a resident's most recent hospice Plan of Care, recertification of terminal illness, and documentation of hospice services provided...

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Based on record reviews and interviews, the facility failed to obtain a resident's most recent hospice Plan of Care, recertification of terminal illness, and documentation of hospice services provided for 1 (Resident #50) of 1 (Resident #50) sampled resident reviewed for hospice. Findings: Review of Resident #50's Minimum Data Set with an Assessment Reference Date of 05/12/2024 revealed, in part, Resident #50 had diagnoses which included stroke, seizure disorder, and malnutrition. Further review revealed Resident #50 received hospice care while a resident in the facility. Review of Resident #50's May 2024 physician's orders revealed, in part, an order to admit Resident #50 to the Contracted Hospice Agency on 02/23/2022. Review of the facility's agreement with the Contracted Hospice Agency dated 02/04/2022 related to Resident #50's hospice services revealed, in part, the following: -The hospice interdisciplinary team, in consultation with the facility, shall review and revise Resident #50's individualized Plan of Care as frequently as Resident #50's condition required, but no less frequently than every 15 days; -All communication between the contracted hospice agency and the facility pertaining to the care and services of Resident #50 shall be documented in Resident #50's clinical record; and, -The facility shall be responsible for obtaining Resident #50's most recent hospice Plan of Care and recertification of terminal illness from the contracted hospice agency. Review of Resident #50's hospice binder revealed, in part, Resident #50's most recent Hospice Interdisciplinary Comprehensive Assessment and Plan of Care Update Report was dated 04/05/2024 for the certification period of 02/23/2024 through 04/22/2024. Review of Resident #50's hospice binder revealed, in part, the most recent recertification of terminal illness by the Contracted Hospice Agency's physician was signed on 02/12/2024 for the certification period of 02/23/2024 through 04/22/2024. Review of Resident #50's hospice binder revealed, in part, Resident #50's most recent contracted hospice agency's visit note documenting the delivery of hospice services was dated 04/08/2024. There was no documented evidence and the facility did not present any documented evidence of having any documentation of hospice services from the Contracted Hospice Agency since 04/09/2024. In an interview on 05/15/2024 at 11:18 a.m., Resident #50's Contracted Hospice Agency's Licensed Practical Nurse denied the facility attempted to obtain current hospice documentation from the Contracted Hospice Agency. In an interview on 05/15/2024 at 3:03 p.m., S2Director of Nursing (DON) confirmed Resident #50's hospice binder did not include any documentation since 04/09/2024. S2DON stated due to a change in staff. S2DON further indicated there was not a designated facility staff member to ensure Resident #50's hospice documentation was current.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on record review, observations, and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) completed hand hygiene during incontinence and catheter care for 1 (Resident #57...

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Based on record review, observations, and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) completed hand hygiene during incontinence and catheter care for 1 (Resident #57) of 1 (Resident #57) residents reviewed for catheter care. Findings: Review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, reviewed on 01/24/2024 revealed, in part, staff should perform hand hygiene before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with bodily fluids, and after removing gloves. Further review revealed the use of gloves does not replace hand washing/hand hygiene, and glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections. Review of Resident #57's Minimum Data Set with an Assessment Reference Date of 02/27/2024 revealed, in part, Resident #57 had a urinary catheter (a device that sits in the bladder and collects urine), was always incontinent of bowel, and had a urinary tract infection within the last 30 days. Review of Resident #57's progress note dated 03/22/2024 revealed, in part, Resident #57 had a urinary tract infection and was to receive 7 days of antibiotics for treatment. Observation on 05/15/2024 at 3:05 p.m. revealed S17CNA entered Resident #57's room and put on gloves without performing hand hygiene. S17CNA then removed Resident #57's soiled brief, wiped stool from Resident #57's buttocks, disposed of Resident #57's soiled brief, and then removed and discarded her gloves into the trash can. S17CNA did not complete hand hygiene, put on a new pair of gloves, and cleansed Resident #57's genitals and catheter tubing. Further observation revealed S17CNA discarded her gloves into the trash can and exited Resident #57's room without completing hand hygiene. In an interview on 05/16/2024 at 3:40 p.m., S17CNA confirmed she did not perform hand hygiene when she provided incontinence and catheter care to Resident #57 in the above documented observation, and should have. In an interview on 05/16/2024 at 12:29 p.m., S4Corporate Clinical Specialist confirmed S17CNA should have completed hand when she provided incontinence and catheter care to Resident #57 in the above documented observation.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to: 1. Protect a resident's right to be free from physical abuse by ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to: 1. Protect a resident's right to be free from physical abuse by Resident #239 for 1 (Resident #75) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; 2. Protect a resident's right to be free from physical abuse by Resident #43 and Resident #47 for 2 (Resident #43 and Resident #47) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; 3. Protect a resident's right to be free from verbal abuse and neglect by S11Certified Nursing Assistant (CNA) for 1 (Resident #37) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; and, 4. Protect a resident's right to be free from neglect by S16CNA for 2 (Resident #20 and Resident #23) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect. Findings: Review of the facility's Abuse Prohibition Policy revised 01/01/2024 revealed, in part, neglect occurred when the facility was aware of services that a resident required but failed to provide them to the resident. Further review revealed abused occurred when the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish. 1. Review of Resident #75's record revealed, in part, he was admitted to the facility on [DATE]. Review of Resident #75's Progress Notes revealed, in part, a note written by S13Licensed Practical Nurse (LPN) dated 04/04/2024 indicated Resident #75 was hit on the arm by another resident. In an interview on 05/14/2024 at 11:54 a.m., S8Certified Nursing Assistant (CNA) indicated Resident #239 hit Resident #75's hand. In an interview on 05/14/2024 at 12:02 p.m., S13LPN indicated Resident #75 and Resident #239 were both in wheelchairs and Resident #75's wheelchair tapped the leg rest of Resident #239's wheelchair when passing Resident #239 in the dining room. S13LPN further indicated Resident #239 then hit Resident #75's hand. In an interview on 05/16/2024 at 1:45 p.m., S1Administrator indicated he reviewed the video surveillance footage which revealed Resident #239 hit Resident #75. S1Administrator confirmed Resident #239 physically abused Resident #75, and this should not have happened. 2. Resident #43 Review of Resident #43's record revealed, in part, an admit date of 10/04/2023 and had a diagnosis of late onset Alzheimer's disease. Review of Resident #43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2024 revealed, in part, Resident #43 had a Brief Interview for Mental Status (BIMS) of 6 which indicated her cognition was severely impaired. Further review revealed there was no documentation of having inappropriate behaviors. Review of Resident #43's Care Plan revealed she had the potential to be physically aggressive as evidenced by a witnessed incident on 04/10/2024 in which Resident #43 and Resident #47 were observed hitting each other in the dining room. In an interview on 05/15/2024 at 10:10 a.m., S9Certified Nursing Assistant (CNA) indicated Resident #43 and Resident #47 did not get along and were both verbally fussy with each other in the dining room. S9CNA indicated Resident #47 was moved away from Resident #43 frequently, but Resident #47 continued to go back towards Resident #43. In an interview on 05/16/2024 at 7:33 a.m., S7Licensed Practical Nurse (LPN) confirmed she witnessed Resident #43 and Resident #47 swinging at and hitting each other in the dining room when she was clocking in around 2:00 p.m. S7LPN further indicated she did not know why the fight started and did not see anyone else in the dining room who would have witnessed the cause of the fight. S7LPN also indicated Resident #47 was known to be aggressive with staff and other residents. In an interview on 05/16/2024 at 10:20 a.m., S1Administrator confirmed S7LPN witnessed Resident #43 and Resident #47 intentionally hit each other in the dining room. In an interview on 05/16/2024 at 11:12 a.m., S1Administrator confirmed no one witnessed the cause of the incident between Resident #43 and Resident #47, so there was no way to determine who was the aggressor or who was the victim. S1Adminitrator confirmed the fight between the above mentioned residents was intentional and was not accidental. In an interview on 05/16/2024 at 11:14 a.m., S4Corporate Clinical Specialist confirmed the fight between Resident #43 and Resident #47 was intentional. Resident #47 Review of Resident #47's record revealed, in part, an admit date of 04/16/2021. Further review revealed, in part, Resident #47 had diagnoses of unspecified psychosis. Review of Resident #47's MDS with an ARD of 03/26/2024 revealed, in part, Resident #47 had a BIMS of 7 which indicated Resident #47's cognition was severely impaired. Review of Resident #47's Care Plan revealed, in part, Resident #47 had a behavioral problem, and on 04/10/2024, Resident #47 and Resident #43 were witnessed having a fight in the dining room. 3. Review of Resident #37's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 03/22/2024 revealed, in part, Resident #37 had a BIMS (Brief Interview Mental Status) score of 15 which indicated Resident #37 was cognitively intact. Further review revealed Resident #37 required extensive assistance of 1 person for bed mobility and toilet use, was frequently incontinent of urine, and was always incontinent of bowel. Review of Resident #37's care plan revealed, in part, Resident #37 had an Activities of Daily Living (ADLs) self-care deficit related to debility and weakness. In an interview on 05/15/2024 at 1:54 p.m., Resident #37 indicated in March 2024, she called for assistance and S11Certified Nursing Assistant (CNA) came into her room and told her good luck being changed and cancelled the call light. Resident #37 further indicated she called again for assistance, and did not receive assistance until the next shift. In an interview on 05/15/2024 at 2:07 p.m., S1Administrator indicated Resident #37 complained she waited too long to be changed towards the end of March 2024. S1Administrator further indicated he reviewed the call light log and discovered Resident #37 waited 95 minutes to be changed. S1Administrator further indicated Resident #37 was cognitive and he took her word for the comment of good luck being changed. S1Administrator further indicated S11CNA was terminated on 03/27/2024, after he substantiated Resident #37 was neglected and was verbally abused by S11CNA. S1Administer confirmed Resident #37 should not have been verbally abused nor neglected by S11CNA. 4. Review of the facility's reported incident revealed, in part, on 05/06/2024 Resident #20 and Resident #23 were identified by S14Certified Nursing Assistant (CNA) and S15Licensed Practical Nurse (LPN) to be heavily saturated with urine. Review also revealed Resident #20 alleged S16CNA had not assisted her all shift. Further review revealed the facility substantiated S16CNA neglected Resident #20 and Resident #23 on 05/06/2024. Review of Resident #20's MDS with an ARD of 04/19/2024 revealed, in part, Resident #20 had a BIMS score of 12, which indicated Resident #20 had moderate cognitive impairment. Further review revealed Resident #20 was always incontinent of bowel and bladder and required total dependence on staff for toileting. Review of Resident #23's MDS with an ARD of 03/01/2024 revealed, in part, Resident #23 had a BIMS score of 5, which indicated Resident #23 had severe cognitive impairment. Further review revealed Resident #23 was always incontinent of bowel and bladder and required total dependence on staff for toileting. Review of the facility's Daily Assignment Sign In Sheet for 05/06/2024 revealed S16CNA was assigned Resident #20 and Resident #23 from 6:00 a.m. to 6:00 p.m. In an interview on 05/15/2024 at 2:35 p.m., S15LPN stated when she arrived to work on 05/06/2024, Resident #20's diaper, incontinence pad, and sheets were saturated with urine and feces. S15LPN stated Resident #20 informed her she was not changed all shift. S15LPN further indicated on 05/06/2024, Resident #23 was saturated with urine and full of feces in her wheelchair. S15LPN confirmed Resident #20 and Resident #23's appearance on 05/06/2024 was consistent with not being assisted all shift. Review of S15CNA's written statement revealed, in part, during rounds on 05/06/2024 S15CNA found Resident #23 in her wheelchair soiled with urine and feces. S15CNA was informed by Resident #23 that she had not been changed all day and could smell herself. S15CNA indicated Resident #20 in her bed with her shirt wet with urine and feces covering her sheets and incontinence pad. In an interview on 05/15/2024 at 4:49 p.m., Resident #20 stated there was a shift recently where she was not changed all shift. Resident #20 further indicated that she could not remember what day it occurred or which CNA was assigned to her. In an interview on 05/15/2024 at 4:50 p.m., Resident #23 state she did remember a shift where she did not get changed, but Resident #23 could not remember the day or the CNA assigned to her. In an interview on 05/16/2024 at 1:50 p.m., S1Administrator stated he was informed that Resident #20 and Resident #23 were left soiled on S16CNA's shift. S1Administrator stated he substantiated S16CNA neglected Resident #20 and Resident #23 from Resident #20's and Resident #23's allegations and S14CNA's and S15LPN's statements. S1Administator confirmed Resident #20 and Resident #23 required incontinence assistance from staff and did not receive it. In an interview on 05/16/2024 at 1:55 p.m., S2DON confirmed S16CNA leaving Resident #20 and Resident #23 soiled on 05/06/2024 was neglect.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

Based on record reviews, observations, and interviews, the facility failed to administer a resident's tube feeding water flush as ordered for 1 (Resident #50) of 1 (Resident #50) sampled residents inv...

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Based on record reviews, observations, and interviews, the facility failed to administer a resident's tube feeding water flush as ordered for 1 (Resident #50) of 1 (Resident #50) sampled residents investigated for tube feeding. Findings: Review of Resident #50's Minimum Data Set with an Assessment Reference Date of 02/10/2024 revealed, in part, Resident #50 had dysphagia (difficulty swallowing) and required nutrition and hydration through a feeding tube. Review of Resident #50's May 2024 physician's orders revealed, in part, an order for Resident #50's tube feeding water flush at 150 milliliters (mL) every 6 hours. Review of Resident #50's tube feeding care plan revealed, in part, an intervention for staff to administer Resident #50's tube feeding flush at 150mL every 6 hours. Observation on 05/13/2024 at 10:15 a.m. revealed Resident #50's tube feeding pump was programmed to administer a water flush of 125mL every 4 hours. Observation on 05/14/2024 at 10:57 a.m. revealed Resident #50's tube feeding pump was programmed to administer a water flush of 125mL every 4 hours. Observation on 05/15/2024 at 11:20 a.m. revealed Resident #50's tube feeding pump was programmed to administer a water flush of 125mL every 4 hours. In an interview on 05/15/2024 at 2:27 p.m., S15Licensed Practical Nurse (LPN) indicated Resident #50 had a physician's order for tube feeding water flush of 150mL every 6 hours. Observation on 05/15/2024 at 2:33 p.m. revealed Resident #50's tube feeding pump was programmed to administer a water flush of 125mL every 4 hours. In an interview on 05/15/2024 at 2:34 p.m., S15LPN confirmed Resident #50's tube feeding pump was programmed to administer a water flush of 125mL every 4 hours. S15LPN confirmed Resident #50 was not getting the correct amount of tube feeding water flush. In an interview on 05/15/2024 at 4:09 p.m., S2Director of Nursing confirmed Resident #50's tube feeding water flush should be administered as ordered.

Mar 2024 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident remained free from neglect and psychosocial har...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident remained free from neglect and psychosocial harm when nursing staff failed to provide care and services to a newly admitted resident for 1 (Resident #5) of 19 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) reviewed for neglect. This deficient practice resulted in actual harm on 02/08/2024 at 10:00 p.m. when S6Licensed Practical Nurse (LPN) and S7Certified Nursing Assistant (CNA) both arrived to work at 10:00 p.m. and failed to receive a nursing report (a verbal report on a residents current medical condition and care needs) from the off-going nursing staff that the facility had a new admit, Resident #5. Resident #5 was discovered on 02/09/2024 at approximately 3:00 a.m. sitting alone in her wheelchair in a dark room by S6LPN and S7CNA. Resident #5 indicated she was scared and crying with complaints of pain which required medication. Findings: Resident #5 was admitted to the facility on [DATE] for orthopedic aftercare following a left below the knee surgical amputation. Review of Resident #5's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/15/2024 revealed, in part, a Brief Interview for Mental Status Score (BIMS) of 15. A BIMS score of 15 which indicated Resident #5 was cognitively intact. Further review revealed Resident #5 required substantial to maximal assistance with transfers to and from a bed to a chair or a wheelchair. Review of the facility's documentation for the investigation of Resident #5's allegation of neglect revealed, in part, Resident #5 reported on 02/08/2024 she waited in her room from 10:30 p.m. to approximately 3:00 a.m. for assistance to get in her bed. Resident #5 indicated she had activated the call bell for assistance. Further review revealed Resident #5 indicated on 02/08/2024 at approximately 10:00 p.m. she was provided assistance with toileting and assisted back to her wheelchair. Resident #5 indicated staff entered her room at approximately 3:00 a.m. and told her they were sorry because they were not aware she was in the room and the call bell had not alerted a need for assistance. Further review revealed on 02/09/2024 S1Administrator and S2Director of Nursing (DON) spoke with Resident #5 to discuss the allegation of neglect and determined Resident #5 did not understand how to use the call system. Review of S6LPN's witness form dated 02/09/2024 revealed, in part, S6LPN made rounds by herself and noted Resident #5's room was dark with no movement in the room. S6LPN documented she had not received report from the off-going nurse and had received report from a CNA. Further review revealed when S6LPN placed medications into residents bins she observed medications for Resident #5 so she went to room a and discovered Resident #5 in a dark room sitting in her wheelchair. Resident #5 indicated she had waited for someone to help her all night. Resident #5 requested and received pain medication. Review of Resident #5's February 2024 electronic Medication Administration Record revealed, in part, Resident #5 received Norco Oral Tablet (a pain medication) 10-325 milligram (mg) on 02/09/2024 at 3:55 a.m. for pain rated at a pain level of 5 on a scale of 1-10. Further review revealed the Norco was administered by S6LPN. In an interview on 03/13/2024 at 3:24 p.m., Resident #5 indicated she was admitted to the facility on [DATE]. Resident #5 indicated she arrived in a wheelchair and remained in the wheelchair in her room for supper. Resident #5 indicated she needed to use the bathroom so she pressed the call button but no one came to the room for several hours. Resident #5 indicated at about 3:00 a.m. a staff member came to the room and assisted her to bed. Resident #5 indicated she had cried because she was scared, tired, and alone. Resident #5 indicated she had pain from sitting in her wheelchair and she had put a pillow on the arm of her wheelchair and tried to sleep but she could not sleep. Resident #5 indicated when the staff realized she was in the room they assisted her to bed but she still did not sleep well because she was scared. In an interview on 03/13/2024 at 3:59 p.m., S5Licensed Practical Nurse (LPN) indicated she was the nurse who admitted Resident #5 to the facility on [DATE]. S5LPN indicated she worked the 2:00 p.m. to 10:00 p.m. shift on 02/08/2024. S5LPN indicated S6LPN was her relief on 02/08/2024 at 10:00 p.m. S5LPN indicated when she attempted to give report to S6LPN, but S6LPN replaced, I don't need report as long as everyone is breathing. I'm here to do one job. S5LPN indicated she had wrote Resident #5's name as a new admission on the 24-hour nursing report sheet. In an interview on 03/14/2024 at 9:24 a.m., S3Assisstant Director of Nursing (ADON) indicated it was the expectation when a nurse or a CNA accepts responsibility for the care of a resident they were expected to receive a verbal report from the off-going nurse. S3ADON further indicated the nurses complete the 24-hour nursing report sheet and it was the expectation the oncoming nurse would review the 24-hour nursing report sheet. S3ADON indicated new admissions were documented on the 24-hour nursing report sheet. S3ADON indicated the oncoming CNA was expected to receive report from the off-going CNA. In an interview on 03/14/2024 at 9:54 a.m., S7CNA indicated when she arrived for her shift on 02/08/2024 at 10:00 p.m. a CNA who was also scheduled for the same 10:00 p.m. shift gave her a report and told her room a was not occupied by a resident; therefore, she never went in room a. S7CNA indicated at about 3:00 a.m. S6LPN reported to her she had received medications from the offsite pharmacy for room a and thought there may be a resident in the room. S7CNA indicated she and S6LPN entered room a and Resident #5 was discovered in her wheelchair crying. S7CNA indicated Resident #5 indicated she was scared. In an interview on 03/14/2024 at 11:42 a.m., S1Administrator indicated on 02/09/2024 it was reported to him that Resident #5 wanted to speak to him and S2DON. S1Administrator indicated Resident #5 was admitted on [DATE] and she reported someone took her to the bathroom on the evening of 02/08/2024, put her in her wheelchair in her room, and no one came to check on her or put her in her bed until approximately 3:00 a.m. S1Administrator confirmed he was aware S6LPN had not received a nursing report when she started the 10:00 p.m. shift on 02/08/2024 and S7CNA had not received report from the off-going CNA. S1Administraot indicated he felt Resident #5's allegation of neglect was unsubstantiated because S6LPN and S7CNA did not intend to neglect Resident #5. In an interview on 03/14/24 at 11:42 a.m., S2DON indicated Resident #5 reported she needed assistance to get in bed on the night of 02/08/2024, but no one came to her room to assist her. S2DON indicated Resident #5 reported to her she attempted to lift her walker to attempt to activate the call button on the wall but was unable to reach it with her walker. In an interview on 03/14/2024 at 11:47 a.m., S1DON indicated Resident #5 was neglected because the facility failed to meet her needs on the night of 02/08/2024.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to ensure an incontinent resident dependent on staff for incontinence care received timely incontinence care for 1 (Resident #14) of 19 (Res...

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Based on record reviews and interviews, the facility failed to ensure an incontinent resident dependent on staff for incontinence care received timely incontinence care for 1 (Resident #14) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) sampled residents investigated for incontinence care. Findings: Resident #14 Review of Resident #14's Minimum Data Set (MDS) with an assessment reference date of 01/12/2024 revealed, in part, Resident #14's cognition was intact, was incontinent of bowel and bladder, and dependent on staff for toileting. Review of the facility's investigation documentation for Resident #14 revealed, in part, on 02/11/2024, S13CNA reported Resident #14's bed linens were found wet with brown spots. Further review revealed the accused, S12CNA, reported Resident #14 never indicated she needed to be changed, and S12CNA did not check under the bed covers to see if Resident #14 had an incontinent episode. Review of S13CNA's statement from the facility's investigation documentation revealed, in part, she (S13CNA) went into Resident #14's room on 02/11/2024 around 7:00 p.m. Resident #14's bed was soaked with a brown wet stain. Further review revealed an incontinence pad on top of the bed linens were also soaked. Further review also revealed Resident #14 was also wet up her back, and S13CNA called the floor nurse to observe Resident #14. Review of S20LPN's statement from the facility's investigation documentation revealed, in part, on 02/11/2024 at 8:20 p.m. S13LPN informed her (S20LPN) that Resident #14's bed linens were soiled and was not changed. In an interview on 03/13/2024 at 1:25 p.m., S13CNA stated on 02/11/2024 around 7:00 p.m. she found that Resident #14's incontinence pad was saturated, and when she lifted the pad she discovered the bed linens had a large brown wet stain on it. S13CNA further indicated that Resident 14's adult brief was also saturated. In an interview 03/13/2024 on 1:49 a.m., S14RN indicated she assisted S13CNA on 02/11/2024 with Resident #14's incontinence care. S14RN confirmed Resident #14's incontinence pad and bed linens were wet. In an interview on 03/14/2024 at 6:12 a.m., S12CNA indicated Resident #14 was not provided incontinence care for the entire shift because Resident #14 did not indicate she needed to be changed. In an interview on 03/14/2024 at 1:39 p.m., S2DON indicated dependent/bed bound residents who require total assistance with toileting and who are always incontinent of bladder and bowel should be changed at least once a shift by staff. S2DON confirmed Resident #14 should have been changed by S12CNA before leaving her shift.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of neglect for 6 (Resident #2, Resident #6, Resident #11, Resident #12, Resident...

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Based on record reviews and interviews, the facility failed to conduct a thorough investigation following an allegation of neglect for 6 (Resident #2, Resident #6, Resident #11, Resident #12, Resident #13, and Resident #17) of 19 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) residents investigated for neglect. Findings: Review of the facility's Abuse Prohibition Policy with a revision date of 11/07/2023 revealed, in part, each resident had the right to be free from neglect and the facility will prohibit neglect of residents. Further review of the investigation component of the Abuse Prohibition policy revealed, in part, the facility will complete a thorough investigation to include where and when the incident occurred and interviews and/or written statements from individuals (residents, visitors, or staff), who may have firsthand knowledge of the incident. Further review revealed all documentation of pertinent data to the investigation will be maintained by the facility. Resident #2 Review of the facility's documentation of their investigation for Resident #2's allegation of neglect revealed, in part, the facility was unable to validate the allegation of neglect. Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/2024 revealed, in part, a Brief Interview for Mental Status Score (BIMS) of 15. A BIMS score of 15 indicated Resident #5 was cognitively intact. Further review revealed Resident #2 was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #2's Care Plan revealed, in part, Resident #2 had an Activity of Daily Living (ADL) self-care performance deficit with impaired mobility. Review revealed a documented intervention of substantial to maximal assistance with toileting hygiene. Review of the facility's Device Activity Report dated 01/22/2024 from 12:00 a.m. to 01/23/2024 at 11:59 p.m. revealed Resident #2's call light alarm was activated on 01/23/2024 at 3:35 a.m. and had a reset time of 177 minutes. There was not documented evidence and the facility conducted a thorough investigation following an allegation of neglect. In an interview on 03/13/2024 at 10:05 a.m., S18Certified Nursing Assistant (CNA) indicated on 01/23/2024 she worked on Hall A from 7:00 a.m. to 7:00 p.m. S18CNA stated when she started her shift she went the room located directly across from Resident #2's room, and she observed Resident #2 sitting on the side of the bed. S18CNA stated she entered Resident #2's room and it smelled of urine. S18CNA indicated Resident #2 told her she had been sitting on the side of her bed since 4:45 a.m. and she wanted to get out of the bed, but she needed incontinence care. S18CNA indicated Resident #2's adult disposable brief was saturated and had a strong smell of urine. S18CNA further indicated Resident #2's washable incontinence bed pad was wet. In an interview on 03/13/2024 at 10:30 a.m., S1Administrator indicated he did not interview Resident #2 for the investigation for neglect. S1Administrator indicated he based the decision to determine the allegation was unable to verify on the fact that the accused staff member was in a room with another resident for an extended period of time. S1Administrator indicated the nursing pagers will sound every 4 to 5 minutes until it is reset by staff in the resident's room. S1Administrator confirmed he interviewed a total of 2 CNAs during the investigation. In an interview on 03/13/2024 at 10:47 a.m., S1Administrator indicated the investigation could have been more thorough for the above mentioned allegation of neglect for Resident #2. Resident #6 Review of Resident #6's MDS with an ARD of 02/16/2024 revealed, in part, Resident #6 had a BIMS score of 4, which indicated Resident #4 was severely cognitively impaired. Further review revealed Resident #6 was dependent on staff for toileting and personal hygiene. Review of Resident #6's care plan revealed, in part, an intervention that staff were to clean peri-area with each incontinence episode. Review of a facility's investigation documentation dated 02/13/2024, revealed an allegation of neglect was made related to Resident #6 not receiving incontinence care. In an interview on 03/14/2024 at 1:07 p.m., S17CNA indicated she did not provide a written statement related to the above mentioned 02/13/2024 allegation of neglect. In an interview on 03/14/2024 at 1:15 p.m., S2Director of Nursing (DON) stated she did not receive a written statement related to the above mentioned 02/13/2024 allegation of neglect from S17CNA. In an interview on 03/14/2024 at 1: 25 p.m., S1Administrator indicated he did not obtain a written or verbal statement from S17CNA,who was assigned to Hall b on 02/13/2024 morning shift, related to the above mentioned 02/13/2024 allegation of neglect. Resident #11 In an interview on 03/12/2024 at 1:56 p.m., Resident #11 indicated he was left a soiled brief and the staff took a long time to answer his call bell. Resident #11 further indicated he was the facility for rehabilitation services and was dependent on staff for assistance. In an interview on 03/12/2024 at 3:05 p.m., S15Licensed Practical Nurse (LPN) indicated on 02/13/2024 she observed Resident #11's adult brief and washable incontinence bed pad were saturated with urine. In an interview on 03/12/2024 at 2:09 p.m., S1Administrator was asked for the investigation of 02/13/2024 for Resident #11. S1Adminstrator indicated S19CNA was an agency CNA and was terminated from working at the facility. Review of the investigation presented by S1Administrator revealed, in part, S20LPN had written on a Witness Form that on 02/13/2024 at 4:00 a.m., Resident #11 said he didn't receive incontinence care last night, night, she must have forgot me. Further review revealed S20LPN further written she pulled the sheets back, and he was dry, so I didn't wake him up. In an interview on 03/12/2024 at 2:18 p.m., S1Administrator indicated per the investigation on the Witness Form the CNA documented Resident #11's incontinence adult brief was dry. S1Administrator further reviewed the form again and confirmed the CNA did not say it as it was written per S20LPN. S1Administrator further indicated knowing that the CNA did not say the resident was dry, he would amend and substantiate the facility's documented investigation report for not providing incontinence care. Resident #12 Review of Resident #12's MDS with an ARD of 02/27/2024 revealed, in part, Resident #12 had a BIMS score of 15 which indicated Resident #12's cognition was intact. Further review revealed Resident #12 required a wheelchair for mobility, was dependent on staff for toileting, hygiene, and was always incontinent of bowel. Review of Resident #12's care plan revealed, in part, Resident #12 had deficits in self-care with activities of daily living (ADL's). Further review revealed Resident #12 was encouraged to use the call bell for assistance. Further review revealed Resident #12 was incontinent of bowel and staff was to provide incontinence care after each incontinent episode. Review of the facility's investigation documentation for Resident #12 indicated an incident of possible neglect occurred on 02/11/2024 which indicated Resident #12 alleged he waited for 2 hours to be changed by S11CNA. Further review of the incident investigation documentation revealed no evidence the facility obtained a statement from the floor nurse responsible for Resident #12 on 02/11/2024 at that time of the incident. Review of the facility's Device Activity Report from 02/11/2024 at 12:00 a.m. through 02/11/2024 at 11:59 p.m. revealed, in part, on 02/11/2024 at 4:02 p.m. the call light alarm was activated for Resident #12's room. Further review revealed Resident #12's call light alarm was not cleared until 6:41 p.m., which indicated the call light alarmed for 158 minutes. Resident #13 Record review of Resident #13's MDS with an ARD date of 01/27/2024 revealed, in part, Resident #13 had a BIMS score of 11 which indicated Resident #13's cognition was moderately impaired. Further review revealed Resident #13 required a wheelchair for mobility, was dependent on staff for toileting hygiene, and was always incontinent of bladder and bowel. Review of Resident #13's care plan revealed, in part, Resident #13 had deficits in self-care with ADL's. Further review revealed Resident #13 was dependent on one staff member for toileting, was incontinent of bladder, and staff was to provide incontinence care after each incontinent episode. Review of the facility's investigation documentation for Resident #13 indicated an incident of possible neglect occurred on 02/11/2024 which indicated Resident #13 alleged he waited for a very long time for assistance from S11CNA. Further review of the incident investigation documentation revealed no evidence the facility obtained a statement from the floor nurse responsible for Resident #13 on 02/11/2024 at that time of the incident. Review of the facility's Device Activity Report from 02/11/2024 at 12:00 a.m. through 02/11/2024 at 11:59 p.m. revealed, in part, on 02/11/2024 at 4:40 p.m. the call light alarm was activated for Resident #13's room. Further review revealed Resident #13's call light alarm was not cleared until 7:32 p.m., which indicated the call light alarmed for 171 minutes. In an interview on 03/14/2024 at 12:22 p.m., S1Administer indicated the CNAs have individual pagers, and when call lights were activated by residents in need of assistance, the pager alarms. S1Administrator further indicated the call light alarm can only be cleared when a staff member enters the resident's room and deactivates the call light alarm by pressing a button mounted on the wall. S1Administrator further indicated the floor nurses also monitor the call light alarms at the nurse's stations. In an interview on 03/14/2024 at 1:39 p.m., S2DON confirmed the floor nurses were ultimately responsible to ensure resident all lights were addressed and care needed was provided to the residents. S2DON confirmed the facility did not interview or obtain a statement from S20LPN to determine why the call light alarm had not been answered for Resident #12 and Resident #13 on 02/11/2024 and should have. Resident #17 Review of Resident #17's MDS with an ARD of 02/27/2024 revealed, in part, Resident #17 had a BIMS score of 15 which indicated Resident #17's cognition was intact. Further review revealed Resident #17 was dependent on staff for hygiene, and was always incontinent of bowel and bladder. Review of Resident #17's care plan revealed, in part, Resident #17 had deficits in self-care with ADL's. Further review revealed Resident #17 was encouraged to use the call bell for assistance. Review of the facility's investigation documentation for Resident #17 indicated an incident of possible neglect occurred on 03/02/2024 and 03/03/2024 which indicated when Resident #17 alleged on 03/02/2024 she repeatedly asked S9CNA to be changed throughout the day. Resident #17's nurse, S8LPN, reported while she administered medications Resident #17 asked her to be changed. S8LPN stated she instructed the S9CNA to go and change Resident #17. S8LPN stated she followed-up with S9CNA and she confirmed that S9CNA did assist Resident #17 as instructed by S8LPN. Further review revealed the call log did not reflect the issues Resident #17 was alleging. Review of the Device Activity Report revealed the call light alarm was activated at 10:17 a.m. and took staff 43 minutes to answer. Review of the facility's Device Activity Report revealed, in part, on 03/02/2024 at 10:53 a.m. the call light alarm was activated for Resident #17's room. Further review revealed Resident #17's call light alarm was not cleared until 12:37 p.m. which indicated the call light alarmed for 103 minutes. There was no documented evidence and the facility did not present any documented evidence as to why staff took so long to answer the call light. In an interview on 03/14/2024 at 12:42 p.m. S2DON indicated she was not aware of all the details of the incident that occurred with Resident #17 on the dates of 03/02/2024 and 03/03/2024. S2DON further indicated it was the responsibility of the nurse assigned to the resident to ensure that CNAs were answering calls for assistance and provide appropriate care in a timely manner. S2DON further indicated staff should be caring for residents appropriately and in a timely manner. In an interview 03/14/2024 at 1:45 p.m., S1Administrator indicated the incident with Resident #17 occurred on 03/03/2024 and he was not aware of the incident dated 03/02/2024. S1Administrator indicated he did not notice during his investigation that Resident #17's device activity report revealed that Resident #17 waited 103 minutes for a staff member to come into her room and clear the alarm.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure staff answered call bells to assist residents timely with toi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure staff answered call bells to assist residents timely with toileting and/or incontinence care for 6 residents (Resident #2, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #17) of 19 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) sampled for incontinence care and toileting Findings: Resident #2 Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/2024 revealed, in part, a Brief Interview for Mental Status Score (BIMS) of 15. A BIMS score of 15 indicated Resident #5 was cognitively intact. Further review revealed Resident #2 was frequently incontinent of bladder and always incontinent of bowel. Review of Resident #2's Care Plan with a revision date of 02/13/2024 revealed, in part, Resident #2 had an Activity of Daily Living (ADL) self-care performance deficit with impaired mobility. Review of Resident #2's Care Plan revealed a documented intervention which included substantial to maximal assistance with toileting and hygiene from staff. Review of the facility's Device Activity Report dated 01/22/2024 from 12:00 a.m. to 01/23/2024 at 11:59 p.m. revealed, in part, Resident #2's call bell was activated on 01/23/2024 at 3:35:36 a.m. and had a reset time of 177 minutes and 55 seconds. In an interview on 03/13/2024 at 10:05 a.m., S18Certified Nursing Assistant (CNA) indicated on 01/23/2024 she worked on Hall A from 7:00 a.m. to 7:00 p.m. S18CNA further indicated when she started her shift she went to the room located directly across from Resident #2's room, and observed Resident #2 sitting on the side of the bed. S18CNA indicated she entered Resident #2's room and it smelled of urine. S18CNA indicated Resident #2 told her she had been sitting on the side of her bed since 4:45 a.m. and wanted to get out of the bed but she needed incontinence care. S18CNA indicated Resident #2's adult disposable brief was saturated and had a strong smell of urine. S18CNA further indicated Resident #2's cloth incontinence pad was wet. In an interview on 03/13/2024 at 10:15am, S2Assistant Director of Nursing (ADON) indicated she had talked with Resident #2 on the morning of 01/23/2024, and Resident #2 told her it felt like it took too long for the aide to come when she had pressed the call light button for help. S2ADON indicated she had not seen the Device Activity Report. In an interview on 03/13/2024 at 10:30 a.m., S1Administrator confirmed Resident #2 activated the call bell on 01/23/2024 at 3:35:36 a.m. and it took 177 minutes and 55 seconds to be answered. Resident #10 Review of Resident #10 clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #10's Minimum Data Set, dated [DATE], revealed, in part, he was assessed as being cognitively intact. Review of Resident #10's Care Plan with a target date of 05/05/2024 revealed, in part, he had potential/actual impairment to skin integrity with an intervention to provide incontinence care as needed. Review of the facility's documentation for Resident #10's allegation of not responding to call bell for incontinence care revealed, in part, the witness, S15LPN, entered Resident #10's room and observed his bed was soaked and it appeared to be some time since he was changed. Review of Resident #10's call log revealed, in part, on 02/13/2024 at 4:46 a.m., there was a 102 minute wait time before Resident #10's call light was deactivated. In an interview on 03/14/2024 at 2:04 p.m., S1Administrator indicated based on S15LPN's statement that she observed Resident #10's bed was soaked and it appeared to have been some time since he was changed. S1Administrator further indicated per the call log on 02/13/2024, Resident #10 waited 102 minutes for the call bell to be deactivated. Resident #11 Review of Resident #11's Minimum Data Set, dated [DATE], revealed, in part, Resident #11 was assessed as being cognitively intact. Review of Resident #11's Care Plan with a goal date of 05/07/2024 revealed, in part, Resident #11 had a activities of daily living self-care deficit related to a fracture of the right thigh bone with a intervention of toilet hygiene of substantial/maximum assistance was to be provided by staff. In an interview on 03/12/2024 at 1:56 p.m., Resident #11 indicated at one time he was left soiled with urine and feces, and the staff took a long time to answer his call bell. Resident #11 further indicated he was recovering from a broken knee and needed assistance with personal care from staff. In an interview on 03/12/2024 at 3:05 p.m., S15LPN indicated on 02/13/2024 she observed Resident #11 was incontinent with urine in his adult brief and urine was also observed from his incontinence pad. Resident #12 Review of Resident #12's MDS with an ARD of 02/27/2024 revealed, in part, Resident #12's cognition was intact. Further review revealed Resident #12 required a wheelchair for mobility, was dependent on staff for toileting hygiene, and was always incontinent of bowel. Review of Resident #12's care plan revealed, in part, Resident #12 had deficits in self-care with activities of daily living (ADL's). Further review revealed Resident #12 was encouraged to use the call bell for assistance. Further review also revealed Resident #12 was incontinent of bowel and staff was to provide incontinence care after each incontinent episode. Review of the facility's investigation documentation revealed Resident #12 alleged he waited for 2 hours to receive personal care from S11CNA. Review of the facility's Device Activity Report from 02/11/2024 at 12:00 a.m. through 02/11/2024 at 11:59 p.m. revealed, in part, on 02/11/2024 at 4:02 p.m. the call light alarm was activated for Resident #12's room. Further review revealed Resident #12's call light alarm was not cleared until 6:41 p.m. which indicated the call light alarmed for 158 minutes. In an interview on 03/14/2024 at 1:39 p.m., S2DON confirmed that the floor nurse was ultimately responsible to ensure that call lights were addressed and care was provided by the CNAs. Resident #13 Record review of Resident #13's MDS with an ARD date of 01/27/2024 revealed, in part, Resident #13's cognition was moderately impaired. Further review revealed Resident #13 required a wheelchair for mobility, was dependent on staff for toileting hygiene, and was always incontinent of bladder and bowel. Review of Resident #13's care plan revealed, in part, Resident #13 had deficits in self-care with ADL's. Further review revealed Resident #13 was dependent on one staff member for toileting, was incontinent of bladder, and staff was to provide incontinence care after each incontinent episode. Review of the facility's investigation documentation revealed Resident #13 alleged he waited for a very long time for assistance from S11CNA. Review of the facility's Device Activity Report from 02/11/2024 at 12:00 a.m. through 02/11/2024 at 11:59 p.m. revealed, in part, on 02/11/2024 at 4:40 p.m. the call light alarm was activated for Resident #13's room. Further review revealed Resident #13's call light alarm was not cleared until 7:32 p.m., which indicated the call light alarmed for 171 minutes. In an interview on 03/11/2024 at 11:45 a.m., Resident #13 indicated on 02/11/2024 he had to wait about 2 hours for the CNA to change his adult brief. Resident #13 further stated the CNA told him she was caring for someone else and would be back to change him. In an interview on 03/14/2024 at 12:22 p.m., S1Administer indicated the CNAs have individual pagers and when the call light alarms were activated by a resident for assistance, the CNA's pager alarms. S1Administrator further indicated the call light alarm can only be cleared when a staff member enters the resident's room and deactivates the call light alarm by pressing a button mounted on the wall. S1Administrator further indicated the floor nurses were to also monitor the call light alarms from the nurse's stations. In an interview on 03/14/2024 at 1:39 p.m., S2DON confirmed the floor nurses were ultimately responsible to ensure resident's call lights were answered and care was provided to the residents. Resident #17 Review of Resident #17's clinical record revealed an admit date of 11/16/2023, which included the following diagnoses, in part, morbid (severe) obesity, lack of coordination, and overactive bladder. Record review of Resident #17 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/2024 revealed, in part, Resident #17 was cognitively intact. Further review revealed Resident #17 required was totally dependent on staff and required the physical assistance of two plus staff with bed mobility, transfer, and toileting. Further review revealed she was always incontinent of bladder and bowel. Review of Resident #17's Care Plan with a revision date of 03/06/2024 revealed, in part, Resident #17 would be provided incontinence care as needed. In an interview on 03/11/2024 at 11:15 a.m., Resident #17 indicated on 03/02/2024 through 03/03/2024 S9CertifiedNursingAssistant (S9CNA), was assigned to provide care to her. Resident #17 indicated on 03/02/2024 when her breakfast was delivered that morning, she notified staff that she needed someone to clean her up because she was wet and the staff member told her she would let S9CNA know she needed assistance. Resident #17 further indicated, she did not get assistance from a staff member, so sometime after 10:00a.m. she pressed the call light button, but no staff member responded at that time. Resident #17 also indicated at 11:15 a.m. she called the front desk with her cell phone and S15Licensed Practical Nurse (S15LPN), answered the phone. Resident #17 indicated she then heard S15LPN, announce over the intercom and stated that the resident in her room needed assistance. Resident #17 also indicated, about 4 minutes later, S15LPN called over the intercom again for someone to assist her, but no one responded to the announcement. Resident #17 further indicated, lunch came at approximately noon and she still had not received incontinence care, so she asked the staff member that delivered her lunch, to let S9CNA know she requested to be changed. Resident #17 indicated she waited approximately an hour, and then she notified S8LicensedPracticalNurse (S8LPN), whom came into her room to administer medication, that S9CNA had not changed her yet. Resident #17 then indicated S8LPN's response was that S9CNA was down the hall with another resident and she would notify her that she needed assistance. Resident #17 indicated S9CNA came in with the linen and told her she would be back to change her. Resident #17 indicated she still had not been changed by 2:22 p.m., so she called the front desk on her cell phone to request for someone to change her. Resident #17 indicated S15LPN answered her call and announced over the intercom, that Resident #17 needed assistance. Resident #17 indicated dinner was served, and at approximately 4:48 p.m., S9CNA finally provided incontinence care for her, but by that time she was soaking wet. Resident #17 indicated on 03/03/2024 she notified S9CNA she needed incontinence care, when she delivered her breakfast and her response was she would change her after breakfast. Resident #17 indicated she still waited a little while after breakfast, until S8LPN, arrived in her room around 10:00 a.m. Resident #17 indicated that she notified S8LPN that she was still waiting for S9CNA to change her and S8LPN responded that she would notify S9CNA to come and assist her. Resident #17 indicated S9CNA finally cleaned her around 11:48 a.m., which by that time she was soaking wet. Resident #17 also indicated she reported the incident that occurred on 03/02/2024 and 03/03/2024 to S3Assistant Director Of Nursing (S3ADON) on 03/04/2024. Review of the facility's Device Activity Report dated 03/02/2024 from 12:00 a.m. to 03/03/2024 at 11:59 p.m. revealed Resident #17's call bell was activated on 03/02/2024 at 10:53:46 a.m. and had a reset at 12:37:37 p.m., for a total of 103 minutes and 51 seconds. In an interview on 03/12/2024 at 10:15 a.m. indicated S3ADON the response times for call bells should not exceed 15 minutes. In a telephone interview on 03/13/2024 at 1:57 p.m. S8LPN indicated on the weekend of 03/02/2024 and 03/03/2024, during a med pass Resident #17 indicated she had not been changed yet and requested for S9CNA to provide her with incontinence care. S8LPN further indicated that S9CNA was assigned to Resident #17 on both days. S8LPN further indicated she informed S9CNA that Resident #17 was requesting incontinence care on both days. S8LPN also indicated S9CNA responded by stating that she was in the room getting another resident up and she would change Resident #17 after finished with that resident. S8LPN further indicated she asked S9CNA if she went into Resident #17's room but I didn't actually ask her if she provided incontinence care for the resident or not, nor did she go into the room and follow-up with Resident #17 to make sure she was provided incontinence care. S8LPN indicated on Sunday Resident #17 complained to her that she needed to be changed and she had to ask S9CNA to go her room to change Resident #17, but she did not follow up with S9CNA to determine whether she actually provided incontinence care to Resident #17. S8LPN further indicated she should have followed- up with S9CNA to make sure she provided incontinence care to Resident #17 but did not. In an interview on 03/14/2024 at 12:42 p.m., S2DirectorOfNursing (S2DON) indicated, it is our job as nurses to make sure the residents we are assigned to are being taken care of, and to follow- up with the CNAs to make sure that they have done their job to care for the residents. In an interview on 03/14/2024 at 1:45 p.m., S1Administrator confirmed Resident #17 activated the call bell on 03/02/2024 at 10:53:46 a.m. and it had a reset time of 103 minutes and 51 seconds to be answered. S1Administrator further confirmed that 103 minutes and 51 seconds was a long time to wait for a call light to be answered.

Feb 2024 2 deficiencies

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

Based on record reviews and interviews, the facility failed to ensure a plan of care was developed for a resident identified as being at high risk for falls for 1 (Resident #1) of 4 (Resident #1, Resi...

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Based on record reviews and interviews, the facility failed to ensure a plan of care was developed for a resident identified as being at high risk for falls for 1 (Resident #1) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents in which the care plans were reviewed. Findings: Review of Resident #1's record, revealed an admit date of 12/06/2023, and had the following diagnoses: Displaced Bi-malleolar (ankle) fracture of right lower leg, and subsequent encounter for closed fracture with routine healing. Review of Resident #1's Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 12/13/2023, revealed Resident #1 was mildly cognitively impaired, and was dependent on staff for toileting, sit to stand and transfers, putting on/taking off footwear, and lower body dressing. Review of Resident #1's Nurse's Notes revealed on 12/06/2023, Resident #1 was admitted to the facility after a stay at a local hospital due to a fall at home in which he sustained a broken right ankle. Further review revealed a late entry note written on 12/27/2023 that a fall occurred on 12/25/2023, where Resident #1 was found lying on his back on the floor near the foot of his bed. Review of Resident #1's Morse Fall Scales (a method of assessing a resident's likelihood of falling), revealed on 12/06/2023 Resident #1 was assessed as being at moderate risk level for falls. On 12/13/2023, Resident #1 was re-assessed and identified as being at a high risk level for falls. On 12/25/2023, Resident #1 was again assessed as being at a high risk level for falls. There was no documented evidence and the facility did not present any documented evidence that a plan of care was developed for Resident #1 being at high risk for falls prior to being discharged from the facility. In an interview on 02/15/2024 at 12:40 p.m., S8Minimum Data Set (MDS) Coordinator confirmed because Resident #1 was admitted to the facility due to a fall at home that resulted in a fracture, a fall care plan should have been developed upon admit. S8MDS Coordinator then confirmed the fall care plan was not developed until 01/02/2024 which was 3 days after Resident #1 was discharged . In an interview on 02/15/2024 at 1:01 p.m., S3Corporate Nurse reviewed Resident #1's care plan and confirmed there was no fall care plan developed before 01/02/2024. S3Corporate Nurse further confirmed there should have been a fall care plan in place.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to: 1. Ensure a dependent and incontinent resident wit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to: 1. Ensure a dependent and incontinent resident with a history of urinary tract infections was provided incontinence care per the facility's policy and procedures for 1 (Resident #2) of 4 Residents (#1, #2, #3, #4) sampled. 2. Ensure a resident who completed self-catheterization was monitored for urine output and signs and/or symptoms of urinary tract infections for 1 (Resident #4) of 4 residents (#1, #2, #3, #4) sampled. Findings: 1. Review of facility's policy and procedure on Perineal Care revealed, in part, the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation. Further review revealed staff should use a wet wash cloth to clean perineal area and wash from front to back. Review of the Resident #2's EMR (electronic medical record) revealed, Resident #2 was admitted to the facility on [DATE] with a diagnosis of stress incontinence (the sudden, involuntary loss of urine). Review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2023 revealed Resident #2 had a Brief Interview for Mental Status score of 15, which indicated Resident #2 was cognitively intact. Further review revealed Resident #2 was dependent and required one person physical assist for toileting. Further review revealed Resident #2 was always incontinent of bladder. Review of Resident #2's Care Plan revealed, in part, Resident #2 completed antibiotic therapy for a Urinary Tract Infection on 09/16/2023 and 12/20/2023. Further review revealed Resident #2 is always incontinent of bladder with interventions for staff to clean Resident #2's perineal area with each incontinent episode. Observation on 02/14/2024 at 12:52 p.m. revealed S5Certified Nursing Assistant (S5CNA) removed Resident #2's brief, cleaned the top of Resident #2's genital area with a wipe, proceeded to wipe down towards her perineum, (area between the genitals and anus) and then back into Resident #2's genital area three times, front to back then back to front using the same wipe. In an interview on 02/14/2024 at 12:58 p.m., S4Licensed Practical Nurse (S4LPN) acknowledged she saw S5CNA wipe Resident #2 from her genital area down to her perineum and back up to her genital area three times, front to back then back to front using the same wipe. S4LPN further stated S5CNA should have used a different wipe for each pass from her genital area down to perineum to prevent the possibility of a urinary tract infection. In an interview on 02/14/2024 at 1:00 p.m., S5CNA confirmed that while providing incontinence care for Resident #2 she used the same wipe three times going from the genital area down towards the buttocks and back up towards the genital area three times using the same wipe. S5CNA further stated she should not have used the same wipe three times while providing incontinence care because it was improper procedure and could cause an infection for the resident but she was rushing for Resident #2. 2. Review of Resident #4's record revealed an admit date of 02/23/2023 with diagnoses of Neurogenic Bladder and Benign Prostatic Hyperplasia. Review of Resident #4's Minimum Data Set with an ARD of 01/20/2024 revealed Resident #4 had a Brief Interview for Mental Status score of 15, which indicated Resident #4 was cognitively intact. Further review Resident #4 required intermittent catheterization. Review of facility's policy and procedure on Catheter Care, Urinary revealed, in part staff should review resident's care plan to assess for any special needs of the resident. Further review of facility's policy and procedure revealed, in part staff should observe the resident's urine level for noticeable urine increases, when urine increases rapidly, decreases, or if levels stays the same. Further record reviewed revealed, in part staff is to observe for complications associated with urinary catheters, to check urine for unusual appearance: (color, blood, etc.), report complaints of burning, tenderness, or pain, and observe for signs and symptoms of urinary tract infection or urinary retention (difficulty urinating and completely emptying the bladder), and to report to physician or supervisor. Review of Resident #4's Physician Orders for 02/23/2023 to 02/15/2024 revealed an order for Resident #4 to self-catheterize as needed daily. Further review revealed and order for nursing staff to monitor Resident #4 every shift to ensure Resident #4 emptied his bladder. Review of Resident #4's Care Plan revealed a goal to remain free from catheter-related trauma with interventions: Resident #4 to perform self-catheterization, Nursing staff to monitor every shift that Resident #4 was emptying his bladder after self-catheterization, Nursing staff to monitor and document intake and output as per facility policy, Nursing staff to monitor, document, and report to physician for signs and symptoms of discomfort and pain due to self-catheterization, Nursing staff to monitor for burning, blood tinged urine, and signs and symptoms of urinary tract infection (an infection in any part of the urinary system). Review of Resident #4's medical record revealed no doucment3ed evidence and the facility was unable to present any documented evidence Resident #4's post self-catheterization urine volume was monitored by the nurse every shift, Resident #4 was monitored for signs and/or symptoms of urinary tract infections, or Resident #4's intake and output were monitored. In an interview on 02/15/2024 at 12:00 p.m., S2Director of Nursing (DON) confirmed Resident #4 had a physician's order dated 3/28/2023 for nursing to ensure Resident #4's bladder was emptied following self-catheterization every shift. S2DON confirmed there was no documented evidence nursing assessed Resident #4's bladder was emptied following self-catheterization every shift, Resident #4's urine output, or that Resident #4 was monitored for signs and/or symptoms of a urinary tract infections. In an interview on 02/15/2024 at 1:17 p.m., Resident #4 stated nursing staff did not check if his bladder was empty after self-catheterization nor did nursing staff nursing staff keep a record of Resident #4's urine output from self-catheterization. In an interview on 02/15/2024 at 2:13 p.m., S3Corporate Nurse confirmed there was no documentation that nursing ensured Resident #4's bladder was empty following self-catheterization every shift, Resident #4's urine output was monitored, and that Resident #4 was monitored for signs and/or symptoms of a urinary tract infection. S3Corporate Nurse further stated Resident #4's care plan and orders should have been implemented and documented. In an interview on 02/15/2024 at 02:15 p.m., S1Administrator stated Resident #4's care plan and physician orders should have been followed and documented appropriately.

Jan 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure residents were free from misappropriation of property/financial abuse/Exploitation for 1 (Resident #3) of 13 (Resident #1, Resident ...

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Based on record review and interview, the facility failed to ensure residents were free from misappropriation of property/financial abuse/Exploitation for 1 (Resident #3) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for misappropriation of resident property. Findings: Review of the facility's Abuse Prohibition Policy revealed, in part, misappropriation of property/financial abuse/Exploitation was defined as taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. Review of Resident #3's Minimum Data Set with an Assessment Reference Data dated 12/01/2023 revealed, in part, Resident #3 had a Brief Interview of Mental Status score of 15 which indicated being cognitively intact. Further review revealed Resident #3 had a diagnosis of Syringomyelia and Syringobulbia (a disease affecting the spinal cord causing pain), Disease of the spinal cord, and Lower back pain Review of Resident #6's Minimum Data Set with an Assessment reference date of 11/23/2023 revealed, in part, Resident #6 had a Brief Interview of Mental Status score of 15 which indicated being cognitively intact. Review of the facility's reported incident revealed on 12/26/2023 at 4:20 p.m., Resident #3 reported Resident #6 made an unauthorized online purchase using Resident #3's credit card in the amount of $73.24. In an interview on 1/22/2024 at 12:02 p.m., Resident #3 stated Resident #6 was not authorized to make an online purchase of $73.24 using Resident #3's credit card. In an interview on 1/22/2024 at 10:26 a.m., Resident #6 acknowledged using Resident #3's credit card without permission to make an online purchase of $73.24. In an interview on 01/22/2024 at 3:00 p.m., S1 Administrator acknowledged Resident #6 did commit misappropriation of funds by using Resident #3's credit card without Resident #3's permission.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure allegations of resident neglect were reported to the state ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure allegations of resident neglect were reported to the state agency within 24 hours of the allegation for 2 (Resident #4 and Resident #10) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for neglect. Findings: Review of the facility's Abuse Prohibition Policy revealed, in part, the facility will report all allegations of neglect without serious bodily injury within 24 hours of the allegation. Resident #4 Review of Resident #4's Minimum Data Set with an Assessment Reference Date of 12/13/2023 revealed, in part, Resident #4 had diagnoses including Alzheimer's disease, stress incontinence and displaced bimalleolar (a bone in the ankle) fracture of the right lower leg. Further review revealed Resident #4 had a Brief Interview for Mental Status score of 08, which indicated Resident #4 had moderate cognitive impairment. Resident #4 required assistance from staff for activities of daily living and transfers. Review of Resident #4's nurse's note from 12/25/2023 at 6:34 a.m. revealed S9Licensed Practical Nurse (LPN) documented the police arrived at the facility at 4:30 a.m. after Resident #4's family called 911 because Resident #4 stated the call light was ringing for 3 hours and no one checked on him. Review of the facility's list of facility reported incidents revealed no facility reported incident involving Resident #4's allegations of neglect on 12/25/2023. In a telephone interview on 01/22/2024 at 11:17 a.m., S9LPN confirmed the police and emergency medical services (EMS) arrived to the facility on [DATE] around 4:30 a.m. S9LPN stated Resident #4's daughter called 911 because Resident #4 informed his daughter that Resident #4 was in pain and the call light had been on for 3 hours without getting assistance. S9LPN stated S10LPN was acting in the role of charge nurse the morning of 12/25/2023 and informed S2Director of Nursing (DON) and S11Assistant Director of Nursing (ADON) of the incident. In a telephone interview on 01/22/2024 at 11:35 a.m., S10LPN stated EMS and the police were at the facility on 12/25/2023 because Resident #4 alleged he had been unattended for 3 hours without staff assistance. S10LPN stated she informed S2DON and S11ADON of this incident. In an interview on 01/22/2024 at 11:52 a.m., S2Director of Nursing (DON) confirmed Resident #4 claiming to have waited 3 hours for assistant and/or care was an allegation of neglect. S2DON stated it was the facility's protocol that allegations of neglect must be reported to the state agency. In an interview on 01/22/2024 at 12:02 p.m., S1Administrator stated a staff member reported to him that Resident #4's daughter called the police due to Resident #4's allegations of waiting for assistance for 3 hours. S1Adminisrtator confirmed he did not report Resident #4's allegations to the state agency. Resident #10 Review of Resident #10's MDS with an ARD of 01/17/2024 revealed, in part, Resident #10 had a BIMS score of 15, which indicated Resident #10 was cognitively intact. Resident #10 had diagnoses including muscle weakness and transient ischemic attack (a disruption of blood flow in the arteries of the brain). Further review revealed Resident #10 was incontinent of bowel and bladder and required staff assistance for toileting and transfers. Review of a grievance form with an effective date of 01/03/2024 at 11:16 a.m. revealed, in part, a grievance stating on 01/02/2024 Resident #10 reported to S4Social Worker that on 12/30/2023 or 12/21/2024 he pressed his call light at 6:00 a.m., but he did not receive assistance until 2:00 p.m. or 3:00 p.m. In an interview on 01/19/2024 at 10:10 a.m. Resident #10 stated on 12/30/2023 or 12/31/2023 about 6:00 a.m. he activated his call light and informed his aide he wanted to be changed and get up in his chair. Resident #10 stated his aide told him she would be back. Resident #10 further stated he activated his call light several times and no one came to assist him. Resident #10 further stated he informed the staff who served him breakfast and lunch he had not been changed and he wanted to be changed and get assistance to his wheelchair. Resident #10 further stated he did not get changed until 2:00 p.m. or 3:00 p.m. In an interview 01/19/2024 at 2:31 p.m., S4Social Worker stated on 01/02/2024 she checked on Resident #10 and he stated over the weekend he had pressed his call light at 6:00 a.m. to be changed and transferred to his wheelchair. S4Social Worker further stated Resident #10 stated he was not changed or transferred to his wheelchair until 2:00 p.m. or 3:00 p.m. In an interview on 01/19/2024 at 3:19 p.m., S3Corporate Nurse stated the grievance of neglect Resident #10 reported on 01/02/2024 was not investigated or reported to state office. In an interview on 01/19/2024 at 3:20 p.m., S1Administrator stated the grievance of neglect that Resident #10 reported on 01/02/2024 was not investigated or reported to state office.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a thorough investigation following allegations of neglect f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a thorough investigation following allegations of neglect for 2 (Resident #4 and Resident #10) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for neglect. Findings: Review of the facility's Abuse Prohibition Policy revealed, in part, any allegations of neglect made by residents shall be reported to the Abuse Coordinator and investigated immediately. Resident #4 Review of Resident #4's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/2023 revealed, in part, Resident #4 had diagnoses including Alzheimer's disease, stress incontinence and displaced bimalleolar (a bone in the ankle) fracture of the right lower leg. Further review revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 08, which indicated Resident #4 had moderate cognitive impairment. Resident #4 required assistance from staff for activities of daily living and transfers. Review of Resident #4's nurse's note from 12/25/2023 at 6:34 a.m. revealed S9Licensed Practical Nurse (LPN) documented the police arrived at the facility at 4:30 a.m. after Resident #4's family called 911 because Resident #4 stated the call light was ringing for 3 hours and no one checked on him. Review of the facility's list of facility reported incidents revealed no facility reported incident involving Resident #4's allegations of neglect on 12/25/2023. In a telephone interview on 01/22/2024 at 11:17 a.m., S9LPN confirmed the police and emergency medical services (EMS) arrived to the facility on [DATE] around 4:30 a.m. S9LPN stated Resident #4's daughter called 911 because Resident #4 informed his daughter that Resident #4 was in pain and the call light had been on for 3 hours without getting assistance. S9LPN stated S10LPN was acting in the role of charge nurse the morning of 12/25/2023 and informed S2Director of Nursing (DON) and S11Assistant Director of Nursing (ADON) of the incident. In a telephone interview on 01/22/2024 at 11:35 a.m., S10LPN stated EMS and the police were at the facility on 12/25/2023 because Resident #4 alleged he had been unattended for 3 hours without staff assistance. S10LPN stated she informed S2DON and S11ADON of this incident. In an interview on 01/22/2024 at 11:52 a.m., S2DON confirmed Resident #4 claiming to have waited 3 hours for assistance and/or care was an allegation of neglect. In an interview on 01/22/2024 at 12:02 p.m., S1Administrator confirmed he was informed of Resident #4's allegations of neglect from 12/25/2023. S1Administrator stated he had no documented evidence of an investigation for Resident #4's allegation of neglect. In an interview on 01/22/2024 at 12:11 p.m., S2DON confirmed she had no documented evidence of an investigation following Resident #4's allegation of abuse on 12/25/2023. She stated S1Administrator was the abuse coordinator and was responsible for investigating all allegations of neglect. Resident #10 Review of Resident #10's MDS with an ARD of 01/17/2024 revealed, in part, Resident #10 had a BIMS score of 15, which indicated Resident #10 was cognitively intact. Resident #10 had diagnoses including muscle weakness and transient ischemic attack (a disruption of blood flow in the arteries of the brain). Further review revealed Resident #10 was incontinent of bowel and bladder and required staff assistance for toileting and transfers. Review of a grievance form with an effective date of 01/03/2024 at 11:16 a.m. revealed, in part, a grievance stating on 01/02/2024 Resident #10 reported on 12/30/2023 he pressed his call light at 6:00 a.m., but he did not receive assistance until 2:00 p.m. or 3:00 p.m. Further review revealed the grievance was reported to S4Social Worker on 01/02/2024. In an interview on 01/19/2024 at 10:10 a.m. Resident #10 stated on 12/30/2023 or 12/31/2023 about 6:00 a.m. he activated his call light and informed his aide he wanted to be changed and get up in his chair. Resident #10 stated his aide told him she would be back. Resident #10 further stated he activated his call light several times and no one came to assist him. Resident #10 further stated he informed the staff who served him breakfast and lunch he had not been changed and he wanted to be changed and get assistance to his wheelchair. Resident #10 further stated he did not get changed until 2:00 p.m. or 3:00 p.m. In an interview 01/19/2024 at 2:31 p.m. S4Social Worker stated on 01/02/2024 she checked on Resident #10 and he stated over the weekend he had pressed his call light at 6:00 a.m. to be changed and transferred to his wheelchair. S4Social Worker further stated Resident #10 stated he was not changed or transferred to his wheelchair until 2:00 p.m. or 3:00 p.m. S4Social Worker stated she informed S1Administrator during the morning meeting on 01/03/2024 of Resident #10's grievance of not receiving care on 12/31/2023. In an interview on 01/19/2024 at 3:19 p.m., S3Corporate Nurse stated the allegation of neglect Resident #10 reported on 01/02/2024 was not investigated or reported to state agency. In an interview on 01/19/2024 at 3:20 p.m., S1Administrator stated the allegation of neglect that Resident #10 reported on 01/02/2024 was not investigated or reported to the state agency.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to: 1. Protect residents (Resident #10 and Resident #12) from reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to: 1. Protect residents (Resident #10 and Resident #12) from resident to resident physical abuse; and, 2. Ensure a resident (Resident #5) was free from neglect by failing to provide incontinence care timely. This deficient practice was identified for 3 (Resident #10, Resident #12, and Resident #5) of 13 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) sampled residents investigated for abuse and neglect. Findings: 1. Review of the facility's Abuse Prohibition Policy, revised 11/07/2023 revealed, in part, each resident has the right to be free from abuse. Resident #10 Review of Resident #10's record revealed, in part, diagnoses of personal history of transient ischemic attach, and unsteadiness on feet. Review of Resident #10's Quarterly Minimum Data Set with an Assessment Reference Date of 01/17/2024 revealed, in part, a Brief Interview for Mental Status score of 15 which indicates cognitive mental status. Further review revealed Resident #10 had no indication of psychosis and was not on antipsychotics, antidepressants, and antianxiety medications. Review of Resident #11's record revealed, in part diagnoses of unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #11's Quarterly Minimum Data Set with an Assessment Reference Date of 11/14/2023 revealed, in part, a Brief Interview for Mental Status score of 00 which indicates severe cognitive impairment. Further review revealed Resident #11 had no indication of psychosis and was on an antidepressant. Review of a facility reported incident entered on 01/12/2024 at 10:44 a.m. revealed, in part, Resident #10 was pushed on the arm by Resident #11 while in the dining room. In an interview on 01/19/2024 at 10:10 a.m., Resident #10 stated a female resident struck him on his arm in the dining room. Review of the facility's video surveillance footage from 01/12/2024 revealed, Resident #10 was seated in the dining room when Resident #11 wheeled herself to Resident #10 and hit Resident #10 on his right forearm. In an interview on 01/19/2024at 1:18 p.m., S1Administrator stated Resident #11 did hit Resident #10 on the arm which resulted in resident to resident abuse on 01/12/2024. Resident #12 Review of the facility's reported incident entered on 01/16/2024 at 10:02 a.m. revealed, in part, Resident #13 ambulated to Resident #12, pushed Resident #12's wheelchair, and hit Resident #12 on her left arm. Review of Resident #12's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/24/2023 revealed, in part, a BIMS score of 0, which indicated Resident #12 had severe cognitive impairment. Review of Resident #13's MDS with an ARD of 11/16/2023 had a BIMS score of 1, which indicated Resident #13 had severe cognitive impairment. Review of the facility's video surveillance footage from 01/16/2024 at 9:10 a.m. through 9:12 a.m. revealed, Resident #13 hit Resident #12 at least three times on her left arm. In an interview on 01/22/2023 at 12:19 p.m., S1Administrator acknowledged resident to resident abuse occurred between Resident #12 and Resident #13 on 01/16/2024 as verified through video surveillance footage on 01/16/2024 between 9:10 a.m. and 9:12 a.m. 2. Review of the facility's Abuse Prohibition Policy revealed, in part, neglect occurred when the facility was aware of, or should have been aware of, goods or services that a resident required but the facility failed to provide the goods or services to a resident. Resident #5 Review of Resident #5's MDS with an ARD of 12/15/2023 revealed, in part, Resident #5 had a BIMS score of 11, which indicated Resident #5 had moderate cognitive impairment. Review also revealed Resident #5 was frequently incontinent of urine and required maximal assistance for toileting hygiene. Review of Resident #5's care plan for bladder incontinence revealed, in part, interventions for staff to clean Resident #5 with each incontinent episode and provide Resident #5 with adult briefs and/or incontinent pads as needed. In an interview on 01/18/2024 at 12:05 p.m., Resident #5 stated it took a long time for staff to respond when she pressed her call light. In an interview on 01/18/2024 at 12:14 p.m., S7Certified Nursing Assistant (CNA) confirmed Resident #5 had bladder incontinence episodes and Resident #5 was able to use her call light for assistance. S7CNA confirmed there were times when S7CNA arrived to her shift at 7:00 a.m. and found residents saturated with urine. Review of the facility's reported incident revealed, in part, on 12/26/2023, Resident #5's family alleged that Resident #5 did not receive incontinence care and was left excessively wet during the day shift of 12/24/2023. Review of the facility's Device Activity Report revealed, in part, on 12/24/2023 Resident #5's call light was activated: -At 4:50 a.m. for 163 minutes and 6 seconds; -At 9:22 a.m. for 153 minutes and 35 seconds; and, -At 4:58 p.m. for 115 minutes and 6 seconds. In a telephone interview on 01/22/2024 at 1:43 p.m., S8CNA stated she began her shift on 12/24/2023 around 6:00 p.m., and S8CNA was asked by Resident #5's son to provide incontinence care to Resident #5. S8CNA stated Resident #5's gown and sheets were saturated with urine. S8CNA further stated Resident #5's urine had soaked up Resident #5's back and saturated Resident #5's pillow. S8CNA also stated Resident #5's son informed her that no staff had entered Resident #5's room since Resident #5's son's arrival to the facility at 3:00 p.m. S8CNA stated Resident #5 being left saturated in urine was neglect. In an interview on 01/22/2024 at 2:23 p.m., S1Administrator stated he was informed on 12/26/2023 that Resident #5's family reported that Resident #5 was not provided incontinence care on 12/24/2023. S1Administrator stated he started an investigation and discovered Resident #5's call light log revealed excessive wait times. S1Administrator confirmed Resident #5's excessive wait times and facility staff's statements regarding Resident #5 being left saturated with urine was evidence of neglect. In an interview on 01/22/2024 at 2:40 p.m., Resident #5's son stated he arrived to the facility on [DATE] around 3:00 p.m., and facility staff had not entered Resident #5's room until the night shift CNA provided incontinence care around 6:00 p.m. Resident #5's son stated Resident #5's bed linens and pillow were saturated with urine from not being changed timely. In an interview on 01/22/2024 at 2:57 p.m., S2Director of Nursing (DON) confirmed Resident #5's wait times were not acceptable. S2DON also confirmed Resident #5 being left saturated with urine was neglect.

Dec 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on record review and interviews, the facility failed to ensure an alleged violation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the St...

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Based on record review and interviews, the facility failed to ensure an alleged violation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1(Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #R5) sampled residents reviewed for abuse. Findings: Review of Resident #4's S6Social Services Director's written notes or Review of Resident #4's written social service notes dated 11/30/2023 at 9:10 a.m. revealed, in part, BIMS assessment completed with no cues needed. Further review revealed, Resident #4 stated an aid treated me very badly. Review of Resident #4's nurse's note dated 11/30/2023 at 6:18 p.m. by S2Director of Nursing (DON) revealed, in part, head to toe skin check done by S3Assistant Director of Nursing. Further review revealed, Resident #4 was noted with a small discoloration to the left side temporal area with complaints that her head hit the wall and pain to the right rib area. Further review revealed the physician was notified and received new order for right rib x-ray due to pain. In an interview on 12/06/2023 at 12:25 p.m., Resident #4 stated an aide push her head into the wall. Resident #4 stated the aide worked for hospice. Resident #4 stated she reported the aide to the head nurse the morning the day it happened. Resident #4 was unable to recall the date of the incident. In an interview on 12/07/2023 at 1:09 p.m., S1Administrator stated he was notified of the allegation of abuse for Resident #4 on 11/30/2023 in the morning while he was driving to work by S2DON. S2Administror further stated a SIMS was opened on 11/30/2023 at 4:53 p.m. In an interview on 12/07/2023 at 2:34 p.m., S1Administrator stated the facility's abuse policy stated abuse should be reported within 24 hours and he was not sure what the regulation was for reporting abuse. In an interview on 12/07/2023 at 2:40 p.m., S2DON stated she notified the administrator at 8:18 a.m. on 11/30/2023 of Resident #4's allegation of abuse.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and...

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Based on record review and interview, the facility failed to ensure an allegation of abuse was thoroughly investigated for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #R5) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy revised 11/07/2023 revealed, in part, the facility will thoroughly investigate all alleged violations and take appropriate actions. Further review revealed, investigations will be prompt, comprehensive, and responsive to the situation. Further review revealed the procedure for the investigation will include interviews and/or written statements from individuals (residents, visitors or staff) who may have firsthand knowledge of the incident. Further review of the procedure for investigation revealed, examination of the resident alleged to have been abused for appropriate interventions (medical, psychosocial, etc.). Review of Resident #4's nurse's note dated 11/30/2023 at 6:18 p.m. by S2Director of Nursing (DON) revealed, in part, head to toe skin check done by S3Assistant Director of Nursing. Further review revealed, Resident #4 was noted with a small discoloration to the left side temporal area with complaints that her head hit the wall and pain to the right rib area. Further review revealed the physician was notified and received new order for right rib x-ray due to pain. Review of Resident #4's medical record revealed, in part, there was no documented evidence of the x-ray completed on 11/30/2023. In an interview on 12/06/2023 at 12:25 p.m., Resident #4 stated she had an aide push her head into the wall. Resident #4 stated the aide worked for hospice. Resident #4 stated she reported the aide to the head nurse in the morning the day it happened. Resident #4 was unable to recall the date of the incident. In an interview on 12/06/2023 at 2:35 p.m., S3Assistant Director of Nursing (ADON) stated she was asked by the S2Director of Nursing (DON) to complete a head to toe assessment on Resident #4. S3ADON stated during the assessment Resident #4 complained of pain to her ribs and an x-ray was ordered by the physician. S3ADON stated she did not see the x-ray result uploaded in Resident #4's medical record. There was no documented evidence and the facility did not present any documented evidence of a completed initial assessment of Resident #4. In an interview on 12/07/2023 at 1:50 p.m., S2DON stated the x-ray ordered for Resident #4 on 11/30/2023 was not completed and there was no evidence of x-ray results for 11/30/2023.

Oct 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to immediately notify a resident's physician of a change in a resident's ability to tolerate an enteral feeding (a way of delivering nutriti...

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Based on record reviews and interviews, the facility failed to immediately notify a resident's physician of a change in a resident's ability to tolerate an enteral feeding (a way of delivering nutrition directly to the stomach or small intestine through a tube) for 1 (Resident #1) of 2 (Resident #1 and Resident #3) sampled residents investigated for enteral feedings. Findings: Review of Resident #1's MDS (Minimum Data Sheet) with an ARD (Assessment Reference Date) of 07/18/2023 revealed, in part, Resident #1 had a BIMS (brief interview mental status) score of 15 which indicated Resident #1 was cognitively intact. Further review revealed, Resident #1 received 51% or more of calories through a feeding tube (a medical device inserted into the stomach used to administer enteral feedings). Review of Resident #1's nutrition/dietary note dated 08/02/2023 revealed, in part, Resident #1's enteral feeding was Osmolite 1.5 Cal (a tube feeding formula that provides complete, balanced nutrition with high calories and protein) 300 milliliters (ml) four times a day (QID). Further review revealed, Resident #1's nausea persisted, and the recommendation was to increase Osmolite 1.5 Cal to 350 mls QID. Review of Resident #1's administration note dated 08/04/2023 at 12:50 p.m. revealed, in part, Resident #1 only tolerated 240 ml of the Osmolite 1.5 Cal. Review of Resident #1's nurse's note dated 08/05/2023 at 12:37 a.m. revealed, in part, Resident #1 stated I cannot take all that feeding, I can only take one carton. Further review revealed, S6MDS Coordinator administered 230 ml of Osmolite 1.5 Cal, and Resident #1 complained of bloating. Review of Resident #1's nurse note dated 08/05/2023 at 6:36 a.m. revealed, in part, Resident #1 complained of nausea when the enteral feeding was administered to her. Review of Resident #1's physician order dated 08/07/2023 revealed, in part, discontinue the enteral feeding of Osmolite 1.5 Cal 300 ml QID and start the enteral feeding of Osmolite 350 ml QID. Review of Resident #1's administration note dated 08/08/2023 at 11:27 a.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's administration note dated 08/08/2023 at 8:41 p.m. revealed, in part, Resident #1 tolerated 175 ml of the enteral feeding. Review of Resident #1's nurse's note dated 08/10/2023 at 2:12 p.m. revealed, in part, Resident #1 refused the lunch time enteral feeding. Review of Resident #1's administration note dated 08/11/2023 at 9:49 p.m. revealed, in part, Resident #1 tolerated 120 ml of the enteral feeding. Review of Resident #1's administration note dated 08/12/2023 at 12:06 p.m. revealed, in part, Resident #1 tolerated 130 ml of the enteral feeding. Further review revealed, Resident #1 stated I'm full, it's feeling full. Review of Resident #1's administration note dated 08/13/2023 at 12:25 a.m. revealed, in part, Resident #1 stated she was feeling full and refused the enteral feeding. Review of Resident #1's administration note dated 08/13/2023 at 5:36 a.m. revealed, in part, Resident #1 complained of fullness. Review of Resident #1's administration note dated 08/14/2023 at 12:19 p.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's nurse's note dated 08/17/2023 revealed, in part, the bolus enteral feeding was terminated after approximately 180 ml of Osmolite 1.5 Cal was administered to Resident #1. Further review revealed, Resident #1 complained of feeling full. Review of Resident #1's nurse's note dated 08/18/2023 by revealed, in part, Resident #1 requested only half of the enteral feeding. Further review revealed, Resident #1 stated her stomach hurts and she cannot tolerate a full enteral feeding. Review of Resident #1's nurse's note dated 08/21/2023 revealed, in part, Resident #1 only tolerated 120 ml of the enteral feeding. Further review revealed, Resident #1 refused rest of the enteral feeding and stated she was full. Review of Resident #1's administration note dated 08/23/2023 at 12:22 p.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's administration note dated 08/25/2023 at 11:27 a.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's administration note dated 08/28/2023 at 5:19 a.m. revealed, in part, Resident #1 tolerated half of the enteral feeding. Further review revealed, Resident #1 complained of nausea and a full stomach. Review of Resident #1's nurse's note dated 08/30/2023 at 11:47 p.m. revealed, in part, Resident #1 refused the enteral feeding. Review of Resident #1's administration note dated 09/01/2023 at 12:19 p.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's administration note dated 09/06/2023 at 12:37 p.m. revealed, in part, Resident #1 tolerated 150 ml of the enteral feeding. Review of Resident #1's administration record dated 09/13/2023 at 12:33 p.m. revealed, in part, Resident #1 refused the enteral feeding. Further review revealed, Resident #1 stated she was feeling too full. Review of Resident #1's nurse's note dated 09/15/2023 revealed, in part, Resident #1 declined the midnight administration of the enteral feeding. There was no documented evidence and the facility did not provide documented evidence of Resident #1's physician being notified of Resident #1's inability to tolerate the enteral feeding. In an interview on 10/24/2023 at 10:05 a.m., S1Director of Nursing (DON) stated the facility's nurses should assess how the residents tolerated enteral feedings and if a resident did not tolerate their ordered enteral feeding, the resident's physician should be notified. In an interview on 10/24/2023 at 11:55 a.m., S4Medical Director stated she did not receive any communication from the facility staff regarding Resident #1 not tolerating the enteral feeding after the volume was increased.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to provide appropriate treatment and services to enhance a resident's tolerance of enteral feedings (a way of delivering nutrition directly ...

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Based on record reviews and interviews, the facility failed to provide appropriate treatment and services to enhance a resident's tolerance of enteral feedings (a way of delivering nutrition directly to the stomach or small intestine through a tube) for 1 (Resident #1) of 2 (Resident #1 and Resident #3) sampled residents investigated for enteral feedings. Findings: Review of the facility's Enteral Nutrition Policy revealed, in part, the dietitian would monitor residents who were receiving enteral nutrition and make appropriate recommendations for interventions to enhance a resident's tolerance of enteral feedings. Further review revealed, the nursing staff should monitor the resident for signs and symptoms of inadequate nutrition, altered hydration or electrolytes, and worsening conditions. Review of Resident #1's MDS (Minimum Data Sheet) with an ARD (Assessment Reference Date) of 07/18/2023 revealed, in part, Resident #1 had a BIMS (brief interview mental status) score of 15 which indicated Resident #1 was cognitively intact. Further review revealed, Resident #1 received 51% or more of calories through a feeding tube (a medical device inserted into the stomach used to administer enteral feedings). Review of Resident #1's nutrition/dietary note dated 08/02/2023 revealed, in part, Resident #1's enteral feeding was Osmolite 1.5 Cal (a tube feeding formula that provides complete, balanced nutrition with high calories and protein) 300 milliliters (ml) four times a day (QID). Further review revealed, Resident #1's nausea persisted, and the recommendation was to increase Osmolite 1.5 Cal to 350 mls QID. Review of Resident #1's administration note dated 08/04/2023 at 12:50 p.m. revealed, in part, Resident #1 only tolerated 240 ml of the Osmolite 1.5 Cal. Review of Resident #1's nurse's note dated 08/05/2023 at 12:37 a.m. revealed, in part, Resident #1 stated I cannot take all that feeding, I can only take one carton. Further review revealed, S6MDS Coordinator administered 230 ml of Osmolite 1.5 Cal, and Resident #1 complained of bloating. Review of Resident #1's nurse's note dated 08/05/2023 at 6:36 a.m. revealed, in part, Resident #1 complained of nausea when the enteral feeding was administered. Further review revealed, Resident #1 wanted to know what can be done next to help her during the administration of her enteral feeding. Review of Resident #1's physician order dated 08/07/2023 revealed, in part, discontinue the enteral feeding of Osmolite 1.5 Cal 300 ml QID and start the enteral feeding of Osmolite 350 ml QID. Review of Resident #1's administration note dated 08/08/2023 at 11:27 a.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's administration note dated 08/08/2023 at 8:41 p.m. revealed, in part, Resident #1 tolerated 175 ml of the enteral feeding. Review of Resident #1's nurse's note dated 08/10/2023 at 2:12 p.m. revealed, in part, Resident #1 refused the lunch time enteral feeding. Review of Resident #1's administration note dated 08/11/2023 at 9:49 p.m. revealed, in part, Resident #1 tolerated 120 ml of the enteral feeding. Review of Resident #1's administration note dated 08/12/2023 at 12:06 p.m. revealed, in part, Resident #1 tolerated 130 ml of the enteral feeding. Further review revealed, Resident #1 stated I'm full, it's feeling full. Review of Resident #1's administration note dated 08/13/2023 at 12:25 a.m. revealed, in part, Resident #1 stated she was feeling full and refused the enteral feeding. Review of Resident #1's administration note dated 08/13/2023 at 5:36 a.m. revealed, in part, Resident #1 complained of fullness. Review of Resident #1's administration note dated 08/14/2023 at 12:19 p.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's nurse's note dated 08/17/2023 revealed, in part, the bolus enteral feeding was terminated after approximately 180 ml of Osmolite 1.5 Cal was administered to Resident #1. Further review revealed, Resident #1 complained of feeling full. Review of Resident #1's nurse's note dated 08/18/2023 by revealed, in part, Resident #1 requested only half of the enteral feeding. Further review revealed, Resident #1 stated her stomach hurts and she cannot tolerate a full enteral feeding. Review of Resident #1's nurse's note dated 08/21/2023 revealed, in part, Resident #1 only tolerated 120 ml of the enteral feeding. Further review revealed, Resident #1 refused rest of the enteral feeding and stated she was full. Review of Resident #1's administration note dated 08/23/2023 at 12:22 p.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's administration note dated 08/25/2023 at 11:27 a.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's administration note dated 08/28/2023 at 5:19 a.m. revealed, in part, Resident #1 tolerated half of the enteral feeding. Further review revealed, Resident #1 complained of nausea and a full stomach. Review of Resident #1's nurse's note dated 08/30/2023 at 11:47 p.m. revealed, in part, Resident #1 refused the enteral feeding. Review of Resident #1's administration note dated 09/01/2023 at 12:19 p.m. revealed, in part, Resident #1 tolerated 240 ml of the enteral feeding. Review of Resident #1's administration note dated 09/06/2023 at 12:37 p.m. revealed, in part, Resident #1 tolerated 150 ml of the enteral feeding. Review of Resident #1's administration record dated 09/13/2023 at 12:33 p.m. revealed, in part, Resident #1 refused the enteral feeding. Further review revealed, Resident #1 stated she was feeling too full. Review of Resident #1's nurse's note dated 09/15/2023 revealed, in part, Resident #1 declined the midnight administration of the enteral feeding. In an interview on 10/24/202333 at 10:23 a.m., S2Registered Dietician stated Resident #1 didn't want to do the enteral feedings. S2Registered Dietician further stated Resident #1 had a mindset that she was going to eventually pass away so what difference does it make. S2Registered Dietician further stated she recommended increasing the enteral feeding on 08/02/2023 because it was the amount of calories Resident #1 needed to stay nourished. S2Registered Dietician further stated she recommended increasing the enteral feeding despite knowing Resident #1 didn't want the enteral feeding and wasn't tolerating the enteral feeding. In an interview on 10/24/2023 at 11:55 a.m., S4Medical Director stated when a resident doesn't tolerate enteral feedings, her recommendation would be to change the formula, frequency, and/or the volume of the enteral feeding. S4Medical Director also stated Resident #1's enteral feeding volume should have been cut in half, not increased when Resident #1 was not tolerating the enteral feeding. In an interview on 10/24/2023 at 12:48 p.m., S5Regional Registered Dietician stated given the circumstances of Resident #1 not tolerating the enteral feeding due to her cancer diagnosis, increasing the volume of the enteral feeding was not appropriate. S5Regional Registered Dietician also stated the expectation of the management company would be to attempt a different enteral formula with a different volume and frequency to help Resident #1 tolerate the enteral feeding.

Aug 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure a resident who required assistance from staf...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure a resident who required assistance from staff with toileting received timely assistance to maintain personal hygiene per professional standards. This deficient practice was identified for 2 (Resident #1 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for activities of daily living. Findings: Review of the facility's Perineal Care Policy revealed, in part, the purpose of this procedure is to prevent infections and skin irritation. Review of steps in the procedure revealed, in part, wash hands and apply gloves; clean perineal area; change gloves; reposition; apply thin layer of skin barrier. Review of the facility's Hand Hygiene Policy and Procedure revealed, in part, hand hygiene is the primary means to prevent the spread of infections. Further review of the Policy Interpretation and Implementation of applying and removing gloves revealed, in part, perform hand hygiene before and after applying non-sterile gloves. Resident #1 Review of Resident #1's Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 06/27/2023 revealed, in part, Resident #1 had a brief interview mental status (BIMS) score of 15 which indicated Resident #1 was cognitively intact. Further review revealed, Resident #1 was always incontinent of bowel and bladder. Further review revealed, in part, Resident #1 required total dependence with toilet use. Review of Resident #1's care plan revealed, in part, Resident #1 was care planned for bladder and bowel incontinence with an intervention to clean peri-area following incontinence episodes. Review of the facility's Device Activity Report dated 07/17/2023 revealed, in part, Resident #1's device alarm went off at 5:21 p.m., 5:40 p.m., and 8:36 p.m. In an interview on 08/08/2023 at 3:12 p.m., Resident #1 stated she had a loose bowel movement on 07/17/2023 between 5:00 p.m. and 5:30 p.m. Resident #1 stated she used her call light and requested to be cleaned up. Resident #1 stated S7Certified Nursing Assistant (CNA) and S9CNA told her they were passing trays and they were not able to change her because it was cross contamination. Resident #1 stated S7CNA and S9CNA left at 7:00 p.m. without cleaning her. Resident #1 stated the next shift cleaned her up some time after 8:00 p.m. when she called again. In an interview on 08/09/2023 at 10:58 a.m., S7CNA stated Resident #1 was incontinent and was able to make her needs known. S7CNA stated on 07/17/2023 she was feeding a resident and came out of the room to get a napkin from the extra tray on the cart when she noticed Resident #1's call light was on so she answered the light. Resident #1 stated she had a bowel movement and needed to be changed. S7CNA stated she informed Resident #1 she would let S9CNA, the assigned CNA, know. S7CNA stated at the time of letting S9CNA know Resident #1 needed to be changed S9CNA made a comment I just gave her a bed bath. S7CNA stated she did not provide incontinence care to Resident #1 after she notified S9CNA that Resident #1 requested to be changed. In a telephone interview on 08/09/2023 at 1:04 p.m., S9CNA stated she was caring for Resident #1 on 07/17/2023. S9CNA stated during the evening meal on 07/17/2023 around 5:30 p.m. she was notified by S7CNA that Resident #1's call light was on, reported she had a bowel movement and needed to be changed. S9CNA stated she responded to S7CNA I just gave her a bed bath and continued on with that task she was in the middle of completing. S9CNA stated she did not change Resident #1's soiled brief before leaving the facility on 07/17/2023 at the end of her shift around 7:00 p.m. S9CNA stated she should have checked on Resident #1 to ensure she was cleaned prior to ending her shift. In an interview on 08/09/2023 at 1:40 p.m., S4Assistant Director of Nursing (ADON) stated she worked with Resident #1 on 07/17/2023 and did not provide any incontinence care for Resident #1 on 07/17/2023. In an interview on 08/10/2023 at 10:05 a.m., S2Director of Nursing (DON) stated when Resident #1 reported she had a bowel movement on 07/17/2023 and requested to be changed, Resident #1 should have been changed immediately. S2DON confirmed Resident #1 did not receive incontinence care in a timely manner according to Resident #1's care plan. Resident #5 Review of Resident #5's MDS with an ARD of 06/17/2023 revealed, in part, Resident #5 had a brief interview mental status (BIMS) score of 15 which indicated Resident #5 was cognitively intact. Further review revealed, in part, Resident #5 was always incontinent of bowel and bladder. Further review revealed, in part, Resident #5 required total dependence with toilet use. Review of Resident #5's care plan revealed, in part, Resident #5 was care planned for bladder incontinence with an intervention to clean peri-area following incontinence episodes. Observation on 08/09/2023 at 1:48 p.m. revealed S7CNA and S8CNA applied gloves then used a Hoyer lift to transfer Resident #5 from the wheelchair to the bed to complete incontinence care. S7CNA did not change gloves after performing incontinence care. S8CNA removed gloves and applied clean gloves without washing her hands or using alcohol gel. S8CNA then opened the jar of barrier cream for S7CNA. S7CNA inserted right index and middle finger into the jar, obtained barrier cream, and applied the barrier cream to Resident #5's peri-area. S7CNA then applied clean brief to Resident #5 using the same pair of gloves. S7CNA then removed gloves and applied clean gloves without performing hand hygiene. In an interview on 08/09/2023 at 1:57 p.m., S7CNA stated she did not change her gloves prior to applying to the barrier cream to Resident #5's peri-area. S7CNA stated she should have removed her dirty gloves, performed hand hygiene, and then applied clean gloves prior to applying barrier cream to Resident #5's peri-area. S7CNA stated she should have performed hand hygiene after removing gloves then applied clean gloves. In an interview on 08/09/2023 at 1:59 p.m., S8CNA stated she removed gloves after transferring Resident #5 to the bed, she did not perform hand hygiene prior to putting on a pair of clean gloves. S8CNA stated she should have performed hand hygiene prior to donning clean gloves. In an interview on 08/10/2023 at 10:00 a.m., S2DON stated hand hygiene should be performed before donning gloves and after removing gloves. S2DON confirmed S7CNA should have removed her dirty gloves, performed hand hygiene, and then donned clean gloves prior to applying barrier cream to Resident #5's peri-area. S2DON also confirmed [NAME] and [NAME] should have performed hand hygiene after removing gloves then donned clean gloves.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to have the nurse staffing information posted on a daily basis. Findings: Observation on 08/08/2023 at 9:44 a.m. revealed no posted staffing in ...

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Based on observation and interview, the facility failed to have the nurse staffing information posted on a daily basis. Findings: Observation on 08/08/2023 at 9:44 a.m. revealed no posted staffing in the facility. Observation on 08/09/2023 at 9:05 a.m. revealed no posted staffing in the facility. Observation on 08/09/2023 at 12:45 p.m. revealed no posted staffing in the facility. Observation on 08/09/2023 at 3:30 p.m. revealed no posted staffing in the facility. Observation on 08/10/2023 at 9:55 a.m. revealed posted staffing dated 08/09/2023. In an interview on 08/10/2023 at 10:20 a.m., S2Director of Nursing (DON) stated nurse staffing data should be posted daily. S2DON acknowledged nurse staffing data was not posted on 08/09/2023. S2DON further acknowledged nurse staffing data posted on 08/10/2023 was not current. In an interview on 08/10/2023 at 11:05 a.m., S6Human Resources (HR) stated she was responsible for posting staffing daily. S6HR confirmed she did not post staffing on 08/08/2023. S6HR also confirmed she posted staffing on 08/09/2023 at the end of the day on 08/09/2023. S6HR stated she posted staffing on 08/10/2023 around 10:30 a.m. and it should have been posted at the beginning of the shift. In an interview on 08/10/2023 at 12:05 p.m., S1Administrator stated staffing should have been posted daily at that beginning of each day. S1Administrator confirmed staffing data was not posted daily at the beginning of each shift on 08/08/2023, 08/09/2023, and 08/10/2023.

Jun 2023 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to ensure an injury of unknown origin was reported to the state agency no later than 24 hours after the incident occurred for 1 (Resident #6...

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Based on record reviews and interviews, the facility failed to ensure an injury of unknown origin was reported to the state agency no later than 24 hours after the incident occurred for 1 (Resident #60) reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy revealed, in part, the following: - All new and current employees will receive training and reinforcement on all aspects of this abuse prohibition program. This will be done at the time of initial employee orientation, annually, and through ongoing in-services. The training will include, but is not limited to: - Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to who and when staff and others must report their knowledge related to any alleged violation. Review of Resident #60's Minimum Data Set (MDS) with an Assessment Reference Date of 04/01/2023 revealed, in part, Resident #60 had a Brief Interview for Mental Status score of 04 which indicated severe cognitive impairment. Further review revealed, in part, Resident #60 was always incontinent of bowel and bladder and needed extensive assistance to total dependence with toileting, bathing, and transfers. Review of Resident # 60's nurse's notes entered on 06/20/2023 at 1:39 a.m. by S15Licensed Practical Nurse (LPN), revealed, in part, Aide making rounds to check if resident is clean and dry. Four fingernail markings found to the right posterior upper thigh. Area cleansed and dried. Will monitor for any changes. Review of the facility's Incident Report logs from 12/20/2022 to 06/20/2023revealed, in part, no incidents reported for Resident #60. Review of S15LPN'S personnel record revealed, in part, abuse training test dated 05/03/2023 with a passing score of 100 % and Associate Acknowledgement of Abuse Policy signed by S15LPN. Review of an In-Service Training dated 05/29/2023 revealed, in part, the topic was Abuse and S15LPN's signature was noted under the column titled Names and Job Titles of Personnel Attending. An observation/skin audit on 06/21/2023 at 3:20 p.m. with S16LPN revealed there was 5 linear wounds located on Resident #60's right posterior hip with one area crescent shaped, and the 4 other areas to be round to oblong. In an interview on 06/21/2023 at 3:20 p.m., S16LPN stated she was made aware of Resident #60's wounds by S15LPN at shift change on 06/20/2023. In an interview on 6/21/2023 at 3:50 p.m., S15LPN stated on 06/20/2023 at approximately 1:00 a.m. she was notified by S19Certified Nursing Assistant Resident #60 had 5 marks that looked like fingernail marks on his right posterior hip. S15LPN further stated she examined this area and noted 4 pink, open areas that appeared like fingernail marks on the posterior hip of Resident #60. S15LPN stated she cleaned the area with normal saline and dressed this area with a dressing. S15LPN stated she charted the findings in the nurse's notes, but did not initiate an incident report. S15LPN stated she did not know how to complete an incident report. In an interview on 06/21/2023 at 4:27 p.m., S3Assistant Director of Nursing (ADON) stated she was unaware that wounds of unknown origin were found on Resident #60. S3ADON further stated when skin tears or wounds were discovered of unknown origin an incident report should be initiated by the staff nurse. S3ADON further stated incident reports should be started by the nurse who discovers the incident. S3ADON further stated no incident report was initiated for Resident #60 on 06/20/2023. S3ADON further stated an incident report should have been initiated on Resident #60 when wounds of unknown origin were found on Resident #60's right posterior hip. In an interview on 06/21/2023 at 5:10 p.m., S17LPN stated during report on the morning of 06/20/2023 at 7:00 a.m., S16LPN did not inform her Resident #60 had a wound of unknown origin. In an interview on 06/22/2023 at 2:30 p.m., S2Director of Nursing (DON) and S10Clinical Specialist stated an incident report should be initiated when an injury of unknown origin was discovered by the staff nurse. S2DON stated she was not aware of an injury of unknown origin for Resident #60. S2DON further stated an incident report should have been started on wounds of unknown origin when discovered on Resident #60.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure a thorough investigation was conducted for an alleged abuse incident reported for 1 (Resident #60) sampled resident reviewed for abu...

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Based on record review and interview, the facility failed to ensure a thorough investigation was conducted for an alleged abuse incident reported for 1 (Resident #60) sampled resident reviewed for abuse. Findings: Review of the facility's Abuse Prohibition Policy revealed, in part, the facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, including injuries of unknown origin and will provide notification of information to the proper authorities according to state and federal regulations. Review of Resident #60's Minimum Data Set (MDS) with an Assessment Reference Date of 04/01/2023 revealed, in part, Resident #60 had a Brief Interview for Mental Status score of 04, which indicated severe cognitive impairment. Further review revealed, in part, Resident #60 was always incontinent of bowel and bladder and needed extensive assistance to total dependence with toileting, bathing, and transfers. Review of Resident # 60's nurse's notes entered on 06/20/2023 at 1:39 a.m. by S15Licensed Practical Nurse (LPN), revealed, in part, Aide making rounds to check if resident is clean and dry. Four fingernail markings found to the right posterior upper thigh. Area cleansed and dried. Will monitor for any changes. Review of the facility's Incident Report logs from 12/20/2022 to 06/20/2022 revealed, in part, no incidents reported for Resident #60. Review of S15LPN'S personnel record revealed, in part, Abuse training test dated 05/03/2023 with a passing score of 100 % and Associate Acknowledgement of Abuse Policy signed by S15LPN. An observation/skin audit on 06/21/2023 at 3:20 p.m. with S16LPN revealed 5 linear wounds located on Resident #60's right posterior hip with one area crescent shaped, and the 4 other areas to be round to oblong. In an interview on 6/21/2023 at 3:50 p.m. S15LPN stated on 06/20/2023 at approximately 1:00 a.m. she was notified by S19Certified Nursing Assistant (CNA) Resident #60 had 5 marks that looked like fingernail marks on his right posterior hip. S15LPN further stated she examined Resident #60 and noted 5 linear wounds located on Resident #60's right posterior hip. S15LPN further stated an incident report for wounds of unknown origin was not initiated. In an interview on 06/21/2023 at 4:27 p.m., S3Assistant Director of Nursing (ADON) stated she was unaware that wounds of unknown origin were found on Resident #60. S3ADON further stated when skin tears or wounds were discovered of unknown origin an incident report should be initiated by the staff nurse. S3ADON further stated an incident report should have been initiated on Resident #60 when wounds of unknown origin were found on Resident #60's right posterior hip. In an interview on 06/22/2023 at 2:30 p.m., S2Director of Nursing (DON) and S10Clinical Specialist stated an incident report should have been initiated and an investigation should have been completed including reporting to the state agency when an injury of unknown origin was discovered for Resident #60. S2DON further stated there was no documented evidence and no documented evidence was presented that an investigation was initiated on Resident #60's injury of unknown origin.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility's admission coordinator failed to notify the facility's nursing staff when ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility's admission coordinator failed to notify the facility's nursing staff when a residents code status was changed from a full code (Full code means that if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) to a Do Not Resuscitate (DNR) (DNR means do not call a code or perform cardiopulmonary resuscitation when the person's heart stops beating) per the residents' choice for 1 (Resident #82) of 3 (Resident #81, #82, and #83) residents reviewed as closed records. Findings: Review of Resident #82's record revealed, in part, Resident #82 was admitted to the facility on [DATE]. Review of Resident #82's hospital discharge orders revealed a physician's order for a Full Code. Review of Resident #82's record revealed a Louisiana Physician Orders for Scope of Treatment (LaPOST) was signed by Resident #82 and Resident #82's physician and dated [DATE]. Review of Resident #82's LaPOST revealed DNR/ Do Not Attempt Resuscitation (Allow natural death) was selected as Resident #82's choice of treatment in the event of a cardiopulmonary arrest. Resident #82's LaPOST was uploaded to the electronic medical record on [DATE]. In an interview on [DATE] at 1:17pm, S3Assisitant Director of Nursing (ADON) stated she received report from the discharging hospital on the day Resident #82 was admitted to the facility and S3ADON was informed Resident #82 was a full code. Review of Resident #82's nurse's notes dated [DATE] at 12:30 a.m. revealed, in part, Resident #82 was observed as nonverbal, sluggish, and unable to arouse with a sternal rub. Further review revealed 911 was called and at 12:35 a.m. facility staff initiated Cardiopulmonary Resuscitation (CPR). Review also revealed at 12:41 a.m., Emergency Medical Services (EMS) and police arrived at the facility and CPR was stopped as advised by EMS. In an interview on [DATE] at 2:00 p.m., S4Corporate Clinical Specialist (CCS) confirmed Resident #82's facility transfer orders dated [DATE] revealed a full code. S4CCS further stated Resident #82's LaPOST, which was uploaded to the electronic health record on [DATE], revealed Resident #82's wishes were to be a DNR status, and Resident #82's LaPOST was signed by Resident #82 and Resident #82's physician and dated on [DATE]. S4CCS stated Resident #82's LaPOST was not provided to facility nursing staff, and Resident #82's wishes to change her code status from a full code to a DNR were not communicated to the nursing staff. S4CCS further stated when S5Interim Admissions Coordinator was informed Resident #82 wanted to change from a full code to a DNR status, S5Interim Admissions Coordinator should have contacted the Director of Nursing (DON) and an order should have been obtained and communicated to the nurses. S4CCS stated Resident #82's LaPOST was not provided to the nursing department until it was uploaded into the electronic health record on [DATE]. In an interview on [DATE] at 1:00 p.m., S6Admissions Coordinator stated when a resident wished to change their code status, it was her responsibility to notify S2DON, S3ADON, and S7Social Services Director (SSD). S6Admissions Coordinator further stated she would then initiate a LaPOST document and nursing staff would contact the physician for an order and completion of the LaPOST. In an interview on [DATE] at 2:12 p.m., S7SSD stated S5Interim Admissions Coordinator informed her on [DATE] Resident #82 had selected to be a DNR on her LaPOST, and S5Interm Admissions Coordinator placed the LaPOST in Resident #82's box for the physician to sign during the next physician visit on [DATE]. S7SSD further stated she informed S5Interim Admissions Coordinator that nursing staff should have been informed of Resident #82's wishes to be a DNR, but S5Interim Admissions Coordinator told her the DNR was not valid without a physician's signature on the LaPOST. In an interview on [DATE] at 2:15 p.m., S4CCS confirmed Resident #82's wishes were not honored when CPR was performed on [DATE], because Resident #82's the resident's choice to be a DNR had not been communicated to the nursing staff.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

Based on record review, interview and observation, the facility failed to ensure a licensed professional nurse (LPN) displayed competency during medication administration as evidenced by administering...

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Based on record review, interview and observation, the facility failed to ensure a licensed professional nurse (LPN) displayed competency during medication administration as evidenced by administering medication to a resident which was ordered and dispensed to another resident (Resident #285).This deficient practice was identified for 1 (Resident #285) of 5 (Resident #35, Resident #40, Resident #64, Resident #285, and Resident #434) sampled residents observed for medication administration. Findings: Review of the facility's Administering Medication Policy revealed, in part, medication ordered for a particular resident may not be administered to another resident. Observation of medication administration on 06/21/2023 at 12:15 p.m., revealed S9Licensed Practical Nursing (LPN) obtained a blister card of Ondansetron Hydrochloride (HCL), a medication used for nausea, 4 milligrams (mg) labeled with Resident #16's name was administered to Resident #285. In an interview on 06/21/2023 at 12:15 p.m., S9LPN stated she administered Resident #16's Ondansetron HCL 4 mg medication to Resident #285 because Resident #285's medication was not available. S9LPN stated she had administered Resident #16's Ondansetron HCL 4mg to Resident #285 and confirmed she should not have used another resident's medication. In an interview on 06/21/2023 at 12:47 p.m., S2Director of Nursing stated nurses should not borrow medication from one resident to administer and administer it to another resident.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents' medical records were accurately maintained for 2 (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents' medical records were accurately maintained for 2 (Resident #59 and Resident #61) of 19 residents (Resident #1, Resident #3, Resident #16, Resident #19, Resident #36, Resident #42, Resident #43, Resident #47, Resident #49, Resident #54, Resident #55, Resident #59, Resident #60, Resident #61, Resident #73, Resident #74, Resident #284, Resident #434, and Resident #436) in the total investigation sample reviewed for accurate medical records. Findings: Resident #59 Review of Resident #59's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2023 revealed, in part, Resident #59 had four unstageable pressure injuries (wounds in which the base is covered by a layer of dead tissue) presenting as deep tissue injuries (DTIs) (an injury to the underlying tissue below the skin's surface that results by prolonged pressure to an area of the body). Review of Resident #59's MDS with an ARD of 04/08/2023 revealed, in part, Resident #59 had 5 venous or arterial ulcers present. Review of Resident #59's wound assessments dated 03/09/2023 revealed, in part, Resident #59 had a right great toe DTI, a left great toe DTI, and a right heel DTI. Review of Resident #59's wound assessments dated 03/16/2023,03/23/2023,04/03/2023 revealed, in part, Resident #59 had a right great toe DTI, a left great toe DTI, a right heel DTI, and a left heel DTI. Review of Resident #59's wound assessments dated 04/06/2023 revealed, in part, Resident #59 had a right great toe DTI, a left great toe DTI, and a left heel DTI. Review of Resident #59's wound assessment dated [DATE], 04/20/2023, 04/27/2023, 05/04/2023, 05/11/2023, 05/18/2023, 05/25/2023,06/01/2023, 06/08/2023, 06/15/2023 revealed, in part, Resident #59 had a left great toe DTI, a right heel DTI, and a left heel DTI. Review of Resident #59's March, April, May, and June 2023's physician orders related to Resident #59's left great toe pressure injury revealed, in part, an order dated 03/10/2023 and discontinued on 03/24/2023 to cleanse Resident #59's left great toe pressure injury with wound cleanser, pat dry, paint with betadine (antiseptic used on the skin to treat or prevent skin infections) and cover with a dry dressing every other day and as needed until the wound resolved. Further review revealed, an order dated 03/24/2023 and discontinued on 04/07/2023 to cleanse Resident #59's left great toe pressure injury with wound cleanser, pat dry, apply Bactroban (an antibiotic) and Xeroform (a non-adherent dressing impregnated with a petroleum blend), and cover with a dry dressing every day and as needed until the wound resolved. Further review revealed, an order dated 04/07/2023 to cleanse Resident #59's left great toe pressure injury with wound cleanser, pat dry, paint with betadine and cover with a dry dressing every other day and as needed until the wound resolved. Review of Resident #59's March, April, May, and June electronic treatment administration record (eTAR) revealed, in part, missing documentation that wound care was performed on Resident #59's left great toe pressure injury on 03/11/2023, 03/17/2023, 03/21/2023, 03/31/2023, and 05/23/2023. Review of Resident #59's March, April, May, and June 2023's physician orders related to Resident #59's right great toe pressure injury revealed, in part, an order dated 03/10/2023 and discontinued on 4/21/2023 to cleanse Resident #59's right great toe pressure injury with wound cleanser, pat dry, paint with betadine, and cover with a dry dressing every other day and as needed until the wound resolved. Further review revealed an order dated 04/21/2023 and discontinued on 04/28/2023 to cleanse Resident #59's right great toe injury with wound cleanser, pat dry, apply bactroban and cover with a foam bordered gauze dressing daily and as needed until the wound resolved. Further review revealed an order dated 04/28/2023 and discontinued on 06/01/2023 to cleanse Resident #59's right great toe pressure injury with wound cleanser, pat dry, paint with betadine, and cover with a dry dressing every other day and as needed until the wound resolved. Further review revealed an order dated 06/01/2023 and discontinued on 06/20/2023 to cleanse Resident #59's right great toe pressure injury with wound cleaner, pat dry, apply Bactroban, and cover with a foam bordered gauze dressing daily and as needed until the wound resolved. Review of Resident #59's March, April, May, and June electronic treatment administration record (eTAR) revealed, in part, missing documentation that wound care was performed on Resident #59's right great toe pressure injury 03/11/2023, 03/17/2023, 03/21/2023, 03/31/2023, and 05/23/2023. Review of Resident #59's March, April, May, and June 2023's physician orders related to Resident #59's left heel pressure injury revealed, in part, an order dated 03/17/2023 and discontinued on 06/13/2023 to cleanse Resident #59's left heel pressure injury with wound cleanser, pat dry, paint with betadine, and cover with a dry dressing every other day and as needed until the wound resolved. Further review revealed, an order dated 06/13/2023 to cleanse Resident #59's left heel pressure injury with wound cleanser, pat dry, paint with betadine, and cover with a dry dressing every other day and as needed until the wound resolved. Review of Resident #59's March, April, May, and June electronic treatment administration record (eTAR) revealed, in part, missing documentation that wound care was performed on Resident #59's left heel pressure injury on 03/11/2023, 03/17/2023, 03/21/2023, 03/31/2023, 04/30/2023, and 05/23/2023. Review of Resident #59's March, April, May, and June 2023's physician orders related to Resident #59's right heel pressure injury revealed, in part, an order dated 03/10/2023 to cleanse Resident #59's right heel pressure injury with wound cleanser, pat dry, paint with betadine, and cover with a dry dressing every other day and as needed until the wound resolved. Review of Resident #59's March, April, May, and June electronic treatment administration record (eTAR) revealed, in part, missing documentation that wound care was performed on Resident #59's right heel pressure injury on 03/11/2023. 03/17/2023, 03/21/2023, 03/31/2023, and 04/30/2023. In an interview on 06/22/2023 at 12:00 p.m., the facility's wound care consultant stated Resident #59's right great toe wound, left great toe wound, left heel wound, and right heel wound were caused by peripheral artery disease (the narrowing or blockage of the vessels that carry blood from the heart to the legs) and were not pressure injuries. In an interview on 06/22/2023 at 3:25 p.m., S11Treatment Nurse (TN) stated all of Resident #59's wounds were arterial wounds and not pressure injuries. S11TN further stated that she should have updated Resident #59's wound care orders to reflect the new wound classifications of wounds to Resident #59's right great toe, left great toe, right heel, and left heel. S11TN further stated she should have checked Resident #59's wound care orders for accuracy before she performed wound care. Resident #59 further stated that she should have updated Resident #59's wound assessments to reflect the new wound classifications to Resident #59's left great toe, right heel, and left heel. In an interview on 06/23/2023 at 1:59 p.m., S2DON stated that resident's right heel wound, left heel wound, and left great toe wound were classified as peripheral arterial disease (PAD) wounds as of 03/16/2023 and that Resident #59's assessments and orders should have reflected the change in classification. In an interview on 06/23/2023 at 11:28 a.m., S11TN stated that she had performed Resident #59's wound care to his left great toe wound, right great toe wound, left heel wound, and right heel wound on the above mentioned dates, but that she had failed to document that Resident #59's wound care was completed. S11TN further stated that Resident #59 was not in the facility on 03/31/2023 and that S20TN performed Resident #59's wound care to his left heel wound and right heel wound on 04/30/2023 and had failed to document that wound care was completed. In an interview on 06/23/2023 at 12:28 p.m., S2Director of Nursing (DON) stated S11TN should have accurately documented in the medical record that wound care was provided to Resident #59's wounds on the above mentioned dates. In an interview on 06/23/2023 at 2:08 p.m. S8Minimum Data Set Licensed Practical Nurse (MDS LPN) stated she coded Resident #59's four wounds as DTIs, because S11TN had documented them as such and that Resident #59's four wounds should have been coded as arterial wounds. Resident #61 Review of the facility's matrix, CMS-802, in part, Resident #61 was identified as having a DTI. Review of Resident #61's MDS with an ARD of 05/16/2023 revealed, in part, Resident #61 had one unstageable pressure injury presenting as a DTI. Review of Resident #61's physician orders revealed, in part, an order dated 05/09/2023 and discontinued on 05/18/2023 to cleanse Resident #61's right posterior heel DTI with wound cleansers, pat dry, apply betadine, and cover with a foam gauze daily and as needed until the wound healed. Further review revealed an order dated 05/18/2023 and discontinued on 06/20/2023 to cleanse Resident #61's right posterior heel DTI with wound cleanser, pat dry, apply betadine, and cover with a foam gauze every other day and as needed until the wound healed. Review of Resident #61's May and June 2023's eTAR revealed, in part, no documented evidence that wound care was performed to Resident #61's right posterior heel DTI from 05/09/2023 until 06/20/2023 as ordered except on 05/23/2023. Review of Resident #61's nurse's note dated 05/09/2023 and written by S2DON revealed, in part, Resident #61 had a DTI approximately 1 centimeter (cm) in height by 1 cm in width with a depth of 0 cm on Resident #61's right posterior heel. Review of Resident #61's Weekly Body Skin Check dated 05/09/2023 revealed, in part, Resident #61 had a right posterior heel DTI. Review of Resident #61's Weekly Body Skin Checks dated 05/17/2023, 05/24/2023, 05/31/2023, and 06/07/2023 revealed, in part, Resident #61 had no skin issues. In an interview on 06/22/202 at 11:00 a.m., S2DON stated she noted what she believed to be a small DTI to Resident #61's right posterior heel on 05/09/2023, but S11TN classified Resident #61's right posterior heel wound as a scab. In an interview on 06/22/2023 at 3:25 p.m., S11TN stated she evaluated Resident #61's right posterior heel wound about a week after a DTI was first noted to Resident #61's right posterior heel by S2DON. S11TN stated she classified Resident #61's right posterior heel wound as a scab and not a DTI. S11TN further stated she should have updated Resident #61's wound care orders to reflect the correct classification of Resident #61's right posterior heel wound. In an interview on 06/23/2023 at 10:07 a.m., S8MDS LPN stated she coded Resident #61's right posterior heel wound as a DTI, because S11TN had documented Resident #61's right posterior heel wound as such. In an interview on 06/23/2023 at 12:56 p.m., S2DON stated Resident #61's wound care orders should have accurately reflected Resident #61's right posterior heel wound classification. S2DON further stated Resident #61's right posterior heel wound was inaccurately documented on the MDS as a DTI. S2DON also stated that S11TN should have accurately documented in the medical record that wound care was provided to Resident #61's wounds.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide access to bathroom facilities for residents ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to provide access to bathroom facilities for residents who were independent in wheelchair for 3 (Resident #434, Resident #436, and Resident #437) of 3 sampled residents. Findings: Resident #434 Review of electronic health record revealed Resident #434 was admitted to facility on 06/08/2023 with diagnosis of other specified disorders of peritoneum, other specified surgical aftercare, protein calorie malnutrition, osteoarthritis, gastro esophageal reflux disease, and colon resection. Review of Resident #434's admission Minimum Data Set Assessment with an Assessment Reference date of 06/15/2023 revealed, in part, a Brief Interview for Mental Status score of 15 was cognitively intact. Review of Resident #434's Care plan revealed, in part, the following problems: The resident has bladder incontinence related to estrogen deficiency with goal that resident will be continent during waking hours through target date of 06/27/2023. Interventions included to ensure Resident #434 has an unobstructed path to the bathroom. Observation on 06/20/2023 at 11:34 a.m. revealed Resident #434 lying in bed B next to the window. Bed A was next to the bathroom door and only 18 inches between the bed and bathroom door not allowing for wheelchair access. In an interview on 06/20/2023 at 11:34 a.m., Resident #434 indicated she was only able to access the bathroom if someone assisted her to the bathroom because she could not move the bed A over to get into the bathroom door. In an interview on 06/21/2023 at 9:10 a.m., Resident #434 indicated she could move independently in her wheelchair in her room, but she could not get to the shared bathroom because bed A was too close to the bathroom's door and Resident #434 was unable to move Bed A. Resident #434 indicated staff had to assist her to the bathroom because bed A had to be moved out of the way in order to get into the bathroom door. In an interview on 06/22/2023 at 10:20 a.m., S9Licensed Practical Nurse (LPN) indicated Resident #434 is independent in her wheelchair when she stays in her room. S9LPN indicated Resident #434 was unable to get into bathroom without assistance due to the bed A positioning and the need for bed A to be moved in order to get into bathroom. S9LPN indicated if Resident #434 wanted to go to bathroom she would need assistance for someone to push the bed out of the way. In an interview on 06/22/2023 at 2:15 p.m., S2Director of Nursing (DON), confirmed that the positioning of the bed A in Resident #434's room had to be moved by a CNA in order to allow Resident #434 access to the bathroom. S2DON confirmed that the bed A did not allow Resident #434 to go into the bathroom without assistance therefore it did not promote Resident #434 independence to get into bathroom. S2DON indicated staff had to take Resident #434 into the bathroom because Resident #434 could not move the bed A out of the way to get through the bathroom door. Resident #436 Review of the electronic health record revealed Resident #436 was admitted to facility on 06/15/2023 with diagnoses of acute and chronic respiratory failure, hypertension, apraxia following cerebral infarction and peripheral vascular disease. Review of Resident #436 Admit/Readmit Evaluation on 06/15/2023 revealed, in part, Resident #436 was alert and orientated to person, place, time and situation, and appropriate verbally. Observation on 06/20/2023 at 12:10 p.m. of Resident #436's room revealed bed A by the bathroom door had less than 24 inches of clearance between the bed and bathroom door. In an interview on 06/20/2023 at 12:12 p.m., Resident #436 indicated that he had to use the bathroom facilities outside of his room due to lack of space between bed A and the bathroom door which made it hard for Resident #436 to get into the bathroom. In an interview on 06/21/2023 at 11:30 a.m., Resident #436 indicated he was able to move in his wheelchair short distances without assistance. Resident #436 indicated he can get in the bathroom at times but had to move bed A in order to get into the bathroom door. Resident #436 indicated sometimes he was unable to move bed A out of the way and could not get into the bathroom. In an interview on 06/21/2023 at 11:38 a.m., S12Certified Nursing Assistant (CNA) indicated that Resident #436 could move his wheelchair independently in room. S12CNA indicated when they assisted Resident #436 to the bathroom, the CNAs had to move bed A out of the way to get to the bathroom door. In an interview on 06/22/2023 at 10:15 a.m., S9LPN indicated Resident #436 was able to propel his wheelchair with his left leg independently in his room. S9LPN indicated for Resident #436 to access the bathroom in his room, CNAs had to assist Resident #436 due to bed A had to be moved out of the way in order to get into the bathroom In an interview on 06/22/2023 at 2:15 p.m., S2DON confirmed that Resident #436's roommate's bed (Bed A located next to bathroom door) provided little room for Resident #436 to get into bathroom without having to move the A bed out of the way. S2DON confirmed that bed A's placement prevented Resident #436 from accessing the bathroom independently. Resident #437 Review of the electronic health record revealed Resident #437 was admitted to the facility on [DATE] with the following diagnoses, in part, congestive heart failure, non-displaced fracture of seventh cervical vertebra, metabolic encephalopathy, dysphagia, hypertension, cardiomyopathy and gastro esophageal reflux disease. Review of Resident #437's Admit/Readmit Evaluation dated 06/14/2023 revealed, in part, Resident #437 was alert, oriented to person and situation, and verbally appropriate. Observation on 06/20/2023 at 11:15 a.m. of Resident #437's room revealed the bed A with the right side of bed against the wall and the head board of bed A blocking ¾th of the entrance into the bathroom door. In an interview on 06/21/2023 at 11:15 a.m., Resident #437 indicated if he wanted to wash his hands, face or go to the toilet he would go to bathroom. Resident #437 indicated he was not sure how he would get into the bathroom door since the bed was blocking the doorway. In an interview on 06/21/2023 at 11:37 a.m., S12CNA indicated that Resident #437 was able to propel his wheel chair at times by himself but needed assistance with long distances. S12CNA indicated in order to bring Resident #437 to the bathroom, staff had to move Resident #437's bed out of the way of the shared bathroom's doorway. Observation on 06/22/2023 at 9:05 a.m. of Resident #437's room Revealed the bed A turned with right side of bed against wall and the head board of bed A blocking ¾th of the entrance into the bathroom door. In an interview on 06/22/2023 at 10:15 a.m., S9LPN indicated Resident #437 was independent with wheel chair mobility. S9LPN indicated Resident #437's bed was turned against the wall to allow more space in his room. S9LPN indicated staff had to assist Resident #437 to the bathroom because they had to move the bed away from the bathroom door. In an interview on 06/22/2023 at 2:15 p.m., S2DON confirmed that bed A had stopped resident #437 from being able to use the bathroom facilities independently.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0635 (Tag F0635)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to: 1. Obtain orders for code status (Resident #284 and Resident #4...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to: 1. Obtain orders for code status (Resident #284 and Resident #436); 2. Obtain orders for colostomy care (Resident #434); and, 3. Obtain orders for Jackson Pratt drain care (Resident #434). This deficient practice identified for 3 (Resident #284, Resident #434, and Resident #436) of 4 (Resident #284, Resident #434 ,Resident #436, and Resident #437) residents reviewed for new admission orders in a total sample of 18 residents. Findings: 1.) Resident #284 Review of Resident #284's medical record revealed Resident #284 was admitted to the facility on [DATE]. Review of Resident #284's [DATE] Physician Orders revealed an order for CPR to be administered if needed with a start date of [DATE]. In an interview on [DATE] at 1:54 p.m., S9Licensed Practical Nurse (LPN) stated when a resident was admitted to the facility, a physician's order should be placed in the computer to reflect a resident's code status choice. S9LPN further confirmed Resident #284's physician order for his code status was not entered until [DATE]. In an interview on [DATE] at 4:15 p.m., S10Clinical Specialist stated a physician's order should have been entered upon Resident #284 admitting to the facility to identify Resident #284's code status and it wasn't. 2.) Resident #434 Review of the Colostomy care policy revealed, in part, documentation should include the date and time the colostomy care was provided, name and title of individual who provided the care, any breaks in resident's skin, signs of infection, how resident tolerated the procedure and if resident refused and reason for refusal. Review of the Policy on Jackson Pratt Drain (JP) revealed, in part, empty the bulb every 8 to 12 hours, record amount of drainage and date and time collected it, clean area around drain every day and apply dressing. Review of electronic health record revealed Resident #434 admitted to facility on [DATE] with diagnosis of other specified disorders of peritoneum, other specified surgical aftercare, protein calorie malnutrition, osteoarthritis, Gastro esophageal reflux disease, and colon resection Review of Resident #434's [DATE] physician orders revealed, in part: An order dated [DATE] to monitor JP drain every shift and document amount of drainage output ever shift and as needed, An order dated [DATE] to change colostomy bag/wafer every 3 days and prn, cleanse area around stoma with soap and water, pat dry, apply skin prep and apply bag/wafer, check skin around stoma for redness, irritation, edema and bleeding and empty colostomy bag every shift and prn. Review of Resident #434's nursing skilled charting dated [DATE] revealed, in part, Resident #434 had a right lateral Jackson Pratt (JP) drain. Review of Resident #434's nursing skilled charting for [DATE]-[DATE] revealed, in part, Resident #434 with colostomy. In an interview on [DATE] at 11:45 a.m., S4Corporate Clinical Specialist confirmed there were no orders for JP drain prior to [DATE] and no orders for colostomy care prior to [DATE]. In an interview on [DATE] at 9:35 a.m., S2Director of Nursing indicated the nurses should receive orders for devices such as JP drains and colostomies on admit and follow those orders. DON indicated if order was not present then the floor nurse should call primary physician and get clarification for orders on devices. In an interview on [DATE] at 9:37 a.m., S3 Assistant Director of Nursing indicated that nurses should receive orders on admit on how to take care of devices such as JP drain and colostomy care. S3ADON indicated if no order is present for a device then the floor nurse should clarify with the primary physician. 3.) Resident #436 Review of Resident #436's electronic health record revealed Resident #436 was admitted to facility on [DATE] with diagnoses of acute and chronic respiratory failure, hypertension, apraxia following cerebral infarction and peripheral vascular disease. Review of Resident #436's [DATE] physician orders revealed, in part, an order for CPR dated [DATE]. Review of Resident #436's electronic health record revealed no documented evidence of Resident #436's code status from admit until [DATE]. In an interview on [DATE] at 2:20 p.m., S4Corporate Clinical Specialist confirmed the process for code status was not being done correctly and that the facility would be implementing a new process. S4Corporate Clinical Specialist confirmed that floor nurses should be transcribing code status orders on admit or obtaining a code status on admit and entering it into the electronic health record. In an interview on [DATE] at 2:25 p.m., S2DON indicated that the primary nurse is responsible for transcribing and inputting orders into the electronic health record when a resident was admitted to the facility. S2DON confirmed the primary nurse should have transcribed code status if present on admission orders or should have obtained an order for code status once resident admits.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to: 1.) Ensure residents interventions were updated af...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to: 1.) Ensure residents interventions were updated after a fall for 2 (Resident #43 and Resident #55) of 2 (Resident #43 and Resident #55); 2.) Ensure a resident's interventions listed on the Comprehensive Care Plan were individualized for 1 (Resident #43) of 2 (Resident #43 and Resident #55) residents investigated for falls and; 3.) Ensure a resident's intervention listed in the Comprehensive Care Plan was implemented for 1 (Resident #55) of 2 (Resident #43 and Resident #55) sampled residents reviewed for falls. Findings: 1. Resident #43 Review of the facility's fall policy revealed, in part, the resident's plan of care will be updated to reflect fall interventions. The Interdisciplinary Team (IDT) team would be notified, a Post Fall Review completed, causative factors evaluated and appropriate referrals made (medications review, therapy, restorative, etc.) The post fall review must be completed within 72 Hours of a fall. Review of Resident #43's MDS (Minimum Data Sheet) with an ARD (Assessment Reference Date) of 06/04/2023 revealed, in part, Resident #43 had a Brief Interview of Mental Status (BIMS) of 15 (a score of 13-15 indicated a resident was cognitively intact). Further review of Resident #43's MDS revealed Resident #43 had 2 or more falls with injury since admission. Review of Resident #43's physician orders dated June 2023 revealed, in part, to encourage and assist Resident #43 to center position while in bed to ensure safety and monitor fall mat beside left side bed every shift. Review of Resident #43's care plan with a target date of 09/11/2023 revealed Resident #43 was at risk for falls and injury with falls on 05/13/2023, 05/19/2023, and 05/27/2023. Review revealed a new intervention for the fall on 05/13/2023, 05/19/2023, and 05/27/2023 was not initiated. In an interview on 06/22/2023 at 9:23 a.m., S8Minimum Data Set Licensed Practical Nurse (MDS LPN) stated when a resident had falls the IDT would have a meeting with the Director of Nursing (DON) to discuss the falls, the DON would give instruction on the interventions to implement and the MDS nurse would add them to the care plan. In an interview on 06/22/2023 at 1:08 p.m., S10Clinical Specialist confirmed Resident #43's care plan was missing interventions for falls that occurred on 05/13/2023, 05/19/2023, and 05/27/2023. S10Clinical Specialist stated interventions should have been updated with each fall. 2. Resident #55 Review of Resident #55's medical record revealed, in part, Resident #55 admitted to the facility on [DATE]. Further review revealed, in part, an additional diagnosis of repeated falls. Review of Resident #55 MDS with an ARD of 05/12/2023 revealed Resident #55's BIMS score was 15, which indicated Resident #55 was cognitively intact. Review of Resident #55's Current Physician Orders revealed, in part, an order with a start date of 02/01/2023 that stated Resident #55 would have a fall mat next to her bed. Further review of the order revealed Resident #55 was a fall risk and should be monitored every shift. Review of Resident #55's Comprehensive Careplan revealed Resident #55 was at risk for falls. Review revealed Resident #55 had unwitnessed falls on 01/15/2023, 03/27/2023, 03/30/2023, 04/11/2023, and 06/14/2023 and two additional falls without injury on 05/13/2023 and 05/27/2023. Review revealed an intervention for the unwitnessed fall on 04/11/2023 was initiated on 06/09/2023. Review revealed an intervention for the falls without injury on 05/13/2023 and 05/27/2023 were initiated on 06/09/2023. Further review revealed an intervention for the unwitnessed fall on 06/14/2023 was initiated on 06/21/2023. Observation on 06/20/2023 at 10:29 a.m., revealed Resident #55 lying in her bed with eyes closed. Further observation revealed, Resident #55's grey fall mat folded in the left corner of her room. Observation on 06/21/2023 at 9:29 a.m. revealed Resident #55 lying in her bed with eyes closed. Further observation revealed, Resident #55's grey fall mat folded in the left corner of her room. In an interview on 06/22/2023 at 1:30 p.m., S18MDS Registered Nurse (RN) stated the facility holds a morning meeting every morning and each fall is discussed during that time. S18MDS RN stated if Resident #55's fall was not discussed in the meeting or if S2Director of Nursing does not inform the MDS department of the intervention, then the MDS Department cannot update the careplan. S18MDS RN stated a fall intervention should be updated within 24 hours after the fall has occurred. In an interview on 06/22/2023 at 1:45 p.m., S10Clinical Specialist stated Resident #55's fall careplan should have been updated within 24 hours of the incidents that occurred on 04/11/2023, 05/13/2023, 05/27/2023, 06/14/2023 and it was not. S10Clinical Specialist further stated Resident #55's fall mat should be placed at her bedside when she is in the bed at all times. Observation on 06/23/2023 at 8:10 a.m. revealed, Resident #55 lying in her bed. Further observation revealed Resident #44's grey fall mat noted at the bottom of her bed. In an interview on 06/23/2023 at 8:11 a.m., S9Licensed Practical Nurse (LPN) stated Resident #55 moved her own fall mat. S9LPN stated Resident #55's fall mat should be placed on the right side of her bed at all times. S9LPN further stated Resident #55 was not careplaned for moving her own fall mat. In an interview on 06/23/2023 at 8:14 a.m., Resident #55 stated sometimes staff put her fall mat next to her bed and sometimes they don't. Resident #55 stated most of the time her fall mat stays in the corner of her room folded up. Resident #55 further stated she does not move her fall mat at night. In an interview on 06/23/2023 at 10:57 a.m., S2DON stated her expectation was that an intervention for a fall was to be placed on Resident #55's careplan immediately after the interdisciplinary meeting was held, which was within 24 hours. S2DON stated the MDS department had access to all of Resident #55's incident reports and documentation related to the incident report which contained whatever intervention was put into place for the resident. She stated Resident #55's careplan was unacceptable and should have been updated right after the incidents occurred.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on record reviews, observations, and interviews the facility failed to ensure a medication storage room remained locked for 1 (Medication Room A) of 2 (Medication Room A and Medication Room B) m...

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Based on record reviews, observations, and interviews the facility failed to ensure a medication storage room remained locked for 1 (Medication Room A) of 2 (Medication Room A and Medication Room B) medication rooms observed. Findings: Review of the facility's policy entitled Storage of Medications revised on November 2020 revealed in part, compartments (including rooms) containing drugs and biologicals are locked when not in use. Review of the facility's Pharmacy Consultant Monthly Medication Room Inspection Checklist's dated 04/05/2023, 05/01/2023, and 06/02/2023 revealed, in part, the door to Medication Room A was observed to be unlocked. Observation on 06/21/2023 from 12:30 p.m. through 12:56 p.m. revealed the door to Medication Room A was unlocked, unattended, and medications were stored in the room. In an interview on 06/21/2023 at 12:56 p.m., S13Licensed Practical Nurse (LPN) stated the door to Medication Room A was unlocked and should not be unlocked. In an interview on 06/21/2023 at 12:58 p.m., S3Assistant Director of Nursing stated all medication rooms should be locked or supervised by a nurse at all times. Observation on 06/21/2023 at 1:03 p.m. revealed S14LPN entered and then exited Medication Room A without locking the door. Observation on 06/21/2023 at 1:05 p.m. revealed the door to Medication Room A was unlocked, unattended, and medications were stored in the room. In an interview on 06/22/2023 1:08 p.m., S2Director of Nursing stated the medication storage rooms should not be left unlocked and unsupervised by a nurse.

Dec 2022 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

Based on record reviews and interviews, the facility failed to implement policies and procedures for ensuring an allegation of alleged sexual abuse was reported immediately but not later than 2 hours ...

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Based on record reviews and interviews, the facility failed to implement policies and procedures for ensuring an allegation of alleged sexual abuse was reported immediately but not later than 2 hours after the allegation was made for 1 (Resident #2) of 5 residents sampled. Findings: Review of the facility's Abuse Prohibition Policy revealed, in part, each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Further review revealed any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately. Review of the facility's Incident Report submitted to the state agency entered on August 25th 2022 by S1Administrator, revealed, in part, Resident #2 was the alleged victim of sexual assault. In an interview on 12/15/2022 at 01:08 p.m., Resident #2 stated she had an issue with an employee where she was allegedly sexually abused. Resident #2 further stated she told S2Temporary Nurse Aide (TNA) about the alleged abuse a couple months before S2TNA reported the allegation S1Administrator. In an interview on 12/16/2022 at 11:29 a.m., S1Administrator stated S2TNA reported the alleged sexual abuse involving Resident #2 to her on 08/25/2022. S1Administrator further stated S2TNA had knowledge of the alleged sexual abuse for a couple months prior to when it was reported to administration. In an interview on 12/16/2022 at 1:28 p.m., S1Administrator confirmed S2TNA should have reported the alleged sexual abuse to the abuse coordinator immediately after she received report of it from Resident #2.

GONZALES HEALTHCARE CENTER

The Good

The Bad

The Ugly 52 deficiencies on record

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GONZALES HEALTHCARE CENTER

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